HX64151140 
RC871  .Sch5  Genito-uiinary  and  V 


RECAP 


GERITO-URINARY 


AND 


VEMEREAL  DISEASES 


SCHMIDT 


PEDERSEN 


CoUege  of  S^lipiimni  anb  burgeons! 
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^be  ^ebical  Epitome  Series. 
GENITO-URmARY 

AND 

VENEREAL  DISEASES, 

A  MANUAL  FOR  STUDENTS  AND  PRACTITIONERS. 

BY 

LOUIS   E.  SCHMIDT,  M.Sc,  M.D., 

Associate  Professor  of  Genito- Urinary  Diseases,  Chicago  Policlinic;  Attending  Genito- 
urinary Surgeon  and  Dermatologist,  Alexian  Brothers'  Hospital,  Chicago. 

SERIES    EDITED   BY 

V.  C.  PEDEESEN,  A.M.,  M.  D., 

Recently  Assistant  Demonstrator  of  Anatomy,  College  of  Physicians  and  Surgeons, 

Columbia  University  in  the  City  of  New  York;  House  Surgeon  at  the  New  York 

Hospital;  Assistant  Surgeon  to  the   Out- Patient  Department  of  the 

Roosevelt  Hospital  and  to  the  Vanderbilt  Clinic;  Physician- 

in-Charge,  St.  Chrysostom's  Chapel  Dispensary, 

New  York  City,  etc..  etc. 

ILLUSTRATED    WITH  TWENTY-TWO  ENGRAVINGS. 


LEA   BROTHERS   &   CO., 
PHILADELPHIA    AND    NEW    YOEK. 


Entered  according  to  Act  of  Congress,  in  the  year  1902,  by 

LEA   BROTHERS   &  CO., 

In  the  Office  of  the  Librarian  of  Congress.    All  rights  reserved. 


ELECTROTYPED   BV 
WESTCOTT  St  THOMSON.    PHILADA, 


PRESS    OF 
WM.   J.   DORNAN,    PHILADA. 


UD 


AUTHOR'S  PREFACE. 

£0 


The  present  volume  endeavors  to  cover  the  subject  of 
Genito-urinary  and  Venereal  Diseases  briefly  and  clearly, 
to  afford  a  comprehensive  survey  within  a  compact  space, 
as  a  camera  condenses  a  landscape,  preserving  all  essen- 
tials in  their  proper  place  and  proportion.  In  this  way 
it  has  been  possible  to  devote  special  attention  to  the  more 
important  diseases,  their  diagnosis  and  treatment,  and  to 
present  the  most  trustworthy  and  practical  medical  and 
surgical  therapeutics. 

Though  this  work  represents  in  a  large  measure  the  results 
of  personal  experience,  reference  has  been  freely  made  to 
the  standard  works  of  Keyes  and  Chetwood,  Hyde  and 
Montgomery,  Neisser,  Finger,  Joseph,  von  Fritsch,  Zucker- 
kandl,  Jadassohn,  Kiimmel,  Fuller,  Taylor,  Fiirbringer, 
Sonnenburg,  Schede,  and  Posner,  to  whose  teachings  I  wish 
to  render  my  grateful  acknowledgment. 

Louis  E.  Schmidt. 

Chicago,  September,  1902. 


Digitized  by  the  Internet  Arciiive 

in  2010  witii  funding  from 

Open  Knowledge  Commons 


http://www.archive.org/details/genitourinaryveOOschm 


EDITOR'S  PREFACE. 


In  arranging  for  the  editorship  of  The  Medical  Epitome 
Series  the  publishers  established  a  few  simple  conditions, 
namely,  that  the  Series  as  a  whole  should  embrace  the 
entire  realm  of  medicine ;  that  the  individual  volumes 
should  authoritatively  cover  their  respective  subjects  in  all 
essentials ;  and  that  the  maximum  amount  of  information, 
in  letter-press  and  engravings,  should  be  given  for  a  mini- 
mum price.  It  was  the  belief  of  publishers  and  editor 
alike  that  brief  works  of  high  character  would  render 
valuable  service  not  only  to  students,  but  also  to  practi- 
tioners who  might  wish  to  refresh  or  supplement  their 
knowledge  to  date. 

To  the  authors  the  editor  extends  his  heartiest  thanks  for 
their  excellent  work.  They  have  fully  justified  his  choice 
in  inviting  them  to  undertake  a  kind  of  literary  task  which 
is  always  difficult — namely,  the  combination  of  brevity,  clear- 
ness, and  comprehensiveness.  They  have  equalled  the  con- 
scientious effi)rts  with  which  the  editor  has  performed  his 
duties  from  first  to  last.  Co-operation  of  this  kind  ought 
to  result  in  useful  books,  in  brief  manuals  as  contradistin- 
guished from  mere  corapends. 

In  order  to  render  the  volumes  suitable  for  quizzing,  and 
yet  preserve  the  continuity  of  the  text  unbroken,  the  ques- 
tions have  been  gathered  at  the  end  of  each  chapter.  This 
new  arrangement,  it  is  hoped,  will  be  convenient  alike  to 

students  and  practitioners. 

Victor  C.  Pedeesen. 

New  York,  September,  1902. 

5 


CONTENTS. 


PAGES 

Introduction 17, 18 

Part  I.— Venereal  Diseases -  -       19-46 

Syphilis:  Acquired  Syphilis  ;  The  Syphilodermata ;  Heredi- 
tary Syphilis;  Treatment  of  Syphilis 19-41 

Chaijcroid 41-46 

Part  II.— Genito-Urinary  Diseases - 47-242 

General  Considerations  :  General  Complications ;  Ure- 
thral Fever ;  Gonorrheal  Eheumatism  ;  Hematuria ; 
Pyuria -    •    •        47-53 

Discharges  from  the  Urethra  :  Spontaneous  Discharges ; 

Involuntary  Discharges 54, 55 

Urinary  Examination  :  General  Considerations ;  Thomp- 
son Two-glass  Test;  Posner  Three-glass  Test;  Physical 
and  Chemical  Examination ;  Microscopical  Examina- 
tion ;  Methods  to  Establish  the  Efficiency  of  the  Kidneys       55-62 

Abnormalities  in  the  Act  of  Urination  :  Normal  Mic- 
turition ;  Abnormal  Micturition 62-67 

Examination  of  the  Patient  :  Genito-Urinary  Inspec- 
tion and  Palpation ;  Instrumental  Examination  of  the 
Urethra  and  Bladder ;  Catheterization  or  Sounding  of  the 
Urethra  ;  Urethroscopy  ;    Cystoscopy 67-85 

Case  Histories  and  Eecords 85,  86 

The  Penis  :  Malformations ;  Injuries  ;  Diseases ;  Balanitis 
and  Posthitis;  Herpes  Progenitalis ;  Venereal  Warts; 
Phimosis  and  Paraphimosis ;  Infections  ;  Tumors  .   .    -    •        86-94 

7 


CONTENTS. 

PAGES 

The  Urethra  :  Malformations  ;  Injuries  ;  Benign  Tumors ; 
Malignant  Tumors ;  Specific  Urethritis ;  Non-Specific 
Urethritis  ;  Gonorrhea ;  Urethritis  in  Females  ;  Stricture 
of  the  Urethra ;  Complications  of  Urethritis 94-137 

C!owper's  Glands  and  The  Seminal  Vesicles 137-139 

The  Prostate  Gland;  A  cute  Prostatitis  ;  Parenchymatous 
Prostatitis;  Abscess  of  the  Prostate;  Chronic  Prostatitis; 
Hypertrophy  of  the  Prostate  ;  Neoplasms  ;  Tuberculosis ; 
Prostatic  Concretions  ;  Prostatic  Keurosis  .......    139-159 

The  ScROTtrii,  Testicles,  and  Cords:  Abnormalities  of 
the  Testicle ;  Contusions,  Inflammations,  and  Neoplasms 
of  the  Scrotum;  Hydrocele;  Hematocele;  Varicocele; 
Epididymitis ;  Orchitis ;  Tuberculosis,  Syphilis,  Cysts, 
and  Neoplasms  of  the  Testis  and  Epididymis ;  Neurosis 
of  the  Testis 159-179 

The  Bladder  :  Abnormalities  ;  Ectopia  ;  Hernia ;  Cystocele 
Vaginalis;  Injuries;  Fistula;  Cystitis;  Hypertrophy; 
Neoplasms ;  Foreign  Bodies ;  Stone ;  Neurosis,  Spasm, 
Aton}-,  and  Paralysis  of  the  Bladder ;    Enuresis   ....    179-210 

Sexual  Disorders  of  the  Male  :  Pathological  Losses  of 

Semen;  Impotency  ;  Sterility;  Masturbation 210-218 

The  Ureters  :  Abnormalities  ;  Injuries;  Diseases 218-220 

The  Kidneys  :  Hydronephrosis  ;  Pyelitis ;  Malformations  ; 
Injuries;  " Essential "  Hemorrhages ;  Neuralgia;  Float- 
ing Kidney  ;  Syphilis,  Tuberculosis,  Calculus,  and  Tumors 
of  the  Kidney ;  Perinephritis 220-238 

Operations  on  the  Ureter,  Pelvis  of  the  Kidney,  and 

Kidney:  Nephrorrhaphy ;  Nephrotomy;    Nephrectomy    238-242 


GENITOURINARY  AND  VENEREAL  DISEASES. 


INTRODUCTION. 

The  term  venereal  diseases,  applied  strictly,  should  include 
only  those  diseases  acquired  during  sexual  intercourse.  Neces- 
sarily the  organs  most  often  affected  are  the  genitals,  although 
other  parts  may  first  become  involved. 

Three  distinct  types  of  venereal  disease  are  recognized  : 
gonorrhoea,  chancroid,  and  syphilis.  They  have  one  charac- 
teristic in  common,  and  that  is  they  are  transmitted  by  contact. 
It  is  possible  to  transfer  or  to  inoculate  these  diseases  with 
instruments  or  objects  which  are  infected,  although  the  usual 
manner  is  during  the  sexual  act.  Gonorrhoea  most  always 
infects  the  urethra,  although  other  mucous  membranes  may 
become  affected  without  the  urethra  first  becoming  involved. 
As  regards  syphilis  and  chancroid,  they  appear  most  often  on 
the  genitalia,  yet  it  is  possible  to  inoculate  their  virus  any- 
where on  the  mucous  membranes  or  skin  of  the  body,  when- 
ever there  is  a  loss  in  their  continuity. 

In  the  case  of  gonorrhoea  and  simple  venereal  ulcer  there 
occur  instances  of  pseudo-prototypes  which  show  almost  every 
point  of  similarity,  yet  differ  only  in  their  etiologic  factor ; 
that  is,  the  bacterial  origin  is  different.  In  these  instances  it 
is  necessary  to  bear  in  mind  that  they  may  be  non-venereal 
in  character.  They  may,  however,  be  acquired  during  the 
sexual  act.  Their  clinical  appearances  are  practically  alike, 
consequently  they  may  be  mistaken  for  each  other,  unless 
the  use  of  the  microscope  and  the  culture-media  are  brought 
into  play.  Therefore,  whenever  the  absence  of  the  gono- 
coccus  in  a  discharge  or  of  the  bacillus  Ducrey-Unna  in  the 
2— v.  D.  17 


1 8  INTE  OD  UCTION. 

secretions  of  an  ulcer  is  established,  it  is  possible  at  times  to 
believe  that  they  did  not  arise  from  extra-marital  relations. 
Their  presence  does  not  exclude  the  possibility  of  their  having 
been  acquired  in  an  innocent  manner.  Their  absence  also 
gives  the  outline  of  the  treatment  to  be  established. 

There  are  positive  instances  of  other  diseases  transmitted 
during  the  sexual  act,  but  these  are,  as  it  were,  simply  of  an 
intercurrent  type,  and  cannot  truly  be  classified  under  the 
heading  of  venereal  diseases.  The  more  common  of  these  are 
pedicidosis  pubis,  molluscum  contagiosum,  and  scabies.  As 
they  are  comparatively  rarely  transmitted  at  these  times,  and 
only  accidentally,  their  description  will  be  omitted.  Properly, 
most  of  such  diseases  belong  to  the  domain  of  dermatology, 
and  will  be  found  suitably  described  in  the  volume  on  that 
subject. 

QUESTIONS  OlSr  THE  INTEODUCTOEY  PAET. 

What  is  meant  by  venereal  disease? 

Mention  the  three  venereal  diseases. 

Have  they  any  characteristic  which  is  common  to  them  all  ? 

What  is  the  usual  manner  of  infection  ? 

Does  gonorrhoea  ever  become  inoculated  primarily  in  any  other  place  than 
in  the  urethra? 

Are  there  discharges  from  the  urethra  that  are  not  gonorrhoeal  ? 

Are  there  ulcers  which  resemble  the  chancroid,  but  difiPer  in  the  absence  of 
the  Ducrey-Unna  bacillus  ? 

Can  these  be  venereal  ? 

Of  what  value  is  it  to  know  the  etiologic  factor  in  these  cases? 

What  other  diseases  can  be  transmitted  during  the  sexual  act? 

T'o  what  general  class  do  such  other  diseases  belong  ? 


PART  I. 
VENEREAL  DISEASES. 


SYPHILIS. 

Definition. — Syphilis  is  a  disease  characterized  by  a  definite 
course  and  certain  pathological  changes.  It  is  classed  among 
the  infectious  diseases  and  pursues  a  chronic  course.  In  the 
early  stages  it  assumes  the  appearance  of  an  acute  exanthema- 
tous  disease,  and  in  the  later  period  the  characteristic  appear- 
ances of  tuberculosis  and  leprosy  occur. 

Etiology. — It  is  peculiar  to  the  human  race,  and  up  to  the 
present  time  the  carrier  of  infection  is  unknown. 

ACaUIRED  SYPHILIS. 

Syphilis  is  transmitted  : 

1.  By  inoculation.  The  infectious  material  enters  the 
usually  broken  surface  of  either  the  skin  or  the  mucous 
membrane.  There  must  be  a  loss  of  continuity  of  tissue  in 
order  for  the  virus  to  gain  entrance.  When  so  contracted,  it 
is  called  "  acquired,'^  and  often  "  contact/'  syphilis. 

2,  By  the  presence  of  the  infectious  material  in  the  em- 
bryo, or  by  the  transmission  of  the  same  through  the  placenta. 
This  is  called  "  inherited/'  "  hereditary/'  and  "  congenital " 
syphilis. 

Symptoms. — Acquired  syphilis  is  commonly  transmitted  at 
the  time  of  sexual  intercourse,  and  for  this  reason  is  counted 
among  the  venereal  diseases.  Immediately  following  the 
inoculation  the  "period  of  first  incubation"  sets  in.  During 
this  time,  of  from  ten  to  thirty  days,  nothing  noticeable  to 
the  eye  occurs.      Then  a  sclerosis,  a  hardness  of  the  base 

19 


20  SYPHILIS. 

varying  in  thickness,  makes  its  appearance.  This  is  called 
the  initial  or  primary  lesion,  or  hard  chancre.  It  is  the 
beginning  of  the  "  period  of  second  incubation  "  ;  in  other 
words,  the  affection  now  becomes  constitutional.  Practically, 
in  all  cases  the  glands  most  directly  connected  with  the  lesion 
become  markedly  enlarged.  Then,  in  the  course  of  from  four 
to  six  weeks,  all  the  glands  become  more  or  less  involved  ; 
in  other  words,  a  general  adenopathy  occurs. 

Constitutional  (Symptoms. — Malaise,  loss  of  appetite,  head- 
aches, etc.,  arise.  It  is  during  this  period  that  reinoculation 
becomes  impossible.  There  are  a  limited  number  of  cases, 
however,  that  do  not  show  either  any  subjective  or  objective 
symptoms  in  this  period.  At  the  end  of  the  period  of  second 
incubation  the  first  eruption,  which  manifests  itself  as  a  rose- 
ola, comes  to  view.  Then  the  syphilis  is  recognized  as  having 
become  constitutional  and  the  primary  stage  has  passed.  The 
first  incubation  requires  from  three  to  four  weeks  ;  the  second, 
from  three  to  eight  weeks ;  that  is,  from  six  to  ten  w'eeks 
elapse  from  the  time  of  infection  to  the  appearance  of  the  first 
general  eruption. 

Course. — The  course  of  syphilis  from  this  point  is  variable, 
and  recurrences  at  irregular  intervals  and  periods  of  latency 
occur. 

Divisions  of  the  entire  course  of  syphilis  have  been  made 
from  different  standpoints,  such  as  initial  or  invasion  period, 
and  again  into  secondary  and  tertiary  periods  ;  also  into  early 
and  late  signs.  It  must  be  understood  that  it  is  impossible  to 
define  sharply  secondary  and  tertiary,  and  to  distinguish  fun- 
damentally between  early  and  late,  as  they  necessarily  overlap 
each  other,  and  in  some  cases  both  are  present  in  the  same 
patient.  The  most  marked  differences  between  secondary  and 
tertiary  symptoms  are  : 


Secondary. 

Teetiaky. 

1. 

2. 

3. 
4. 

Arise  aud  develop  quickly. 
Symmetrical,     disseminated,    and 

multiple. 
Earely  grouped. 
Highly  infectious. 

1. 

2. 

3. 

4. 

Arise  and  develop  slowly. 
Asymmetrical,       scattered, 

usually  isolated. 
Usually  grouped. 
Not  regarded  so. 

and 

ACQUIRED  SYPHILIS.  21 

Secondary.  Tertiary. 

5.  Heal  without  scars.  5.  Scars  always  follow  loss  of  sub- 

stance. 

6.  Therapeutically  react  to  mercury.       6.  Eeact  to  iodides. 

7.  Predilectiou  for  skin.  7.  Teudency  for  deep-seated    parts, 

notably  viscera. 

8.  Usually  within  first  year  of  infec-      8.  Most  often  in  later  years. 

tion. 

Reinfection. — The  possibility  of  reinfection  is  not  an  absolute 
law,  although  there  are  some  apparently  authentic  cases. 
Probably,  however,  no  reinfection  can  occur  so  long  as  any 
late  symptoms  are  present,  but  only  where  a  prolonged 
period  of  supposed  health  and  of  freedom  from  symptoms 
of  syphilis  has  intervened,  hence  constituting  a  relapse. 

Contagiousness. — All  lesions  belonging  to  primary  and  sec- 
ondary periods,  when  not  covered  by  epithelium,  are  conta- 
gious. The  tertiary  are,  as  a  rule,  probably  not ;  nevertheless, 
if  tertiary  signs  arise  soon  after  the  initial  lesion,  there  is 
great  likelihood  that  they  are  contagious.  The  blood,  espe- 
cially during  the  secondary  stage,  and  crusts  from  other  skin 
diseases  removed  with  underlying  secretion,  may  be  conta- 
gious. 

The  contagiousness  of  syphilis,  so  far  as  is  known,  depends 
on  :  1.  The  age  of  the  disease.  2.  The  treatment  and  char- 
acter of  the  same.  3.  From  the  type  and  localization  of  the 
lesion. 

Only  hereditary  syphilis,  or  from-mother-to-child  syphilis, 
is  recognized  to  exist  without  a  primary  lesion.  In  all  other 
cases  it  is  doubtful  whether  it  occurs,  hence  syphilis  cVemhlee 
is  exceedingly  questionable. 

The  part  played  in  syphilis  by  peculiar  potency  of  the  virus, 
by  age  of  the  individual,  by  idiosyncracy,  and  by  place  of 
inoculation,  is  not  exactly  determined  as  regards  the  severity 
of  its  course. 

The  Initial  Lesion. — Whenever  syphilitic  virus  without  the 
addition  of  any  other  infectious  material  enters  the  skin  or 
mucous  membrane,  a  red  papule  appears  as  the  initial  lesion — 
'primary  sore,  ulcus  durum,  or  Hunterian  chancre.  It  may 
appear  in  different  forms  :  as  an  erosion,  as  a  dry,  scaling,  and 


22  SYPHILIS. 

indurated  papule,  us  an  ulcer,  and  with  various  other  appear- 
ances which  are  more  or  less  uncommon.  Chancres  vary  in 
size  from  that  of  a  minute  pin-head  to  a  silver  dollar.  All 
have  their  appearance  more  or  less  changed  according  to  their 
location,  whether  on  corona  glandis,  intra-urethram,  on  scro- 
tum, tonsils,  tongue,  or  on  any  other  portion  of  the  body. 
Their  appearance  always  varies,  whether  or  not  inoculation 
occurred  on  a  rhagade  or  a  herpetic  eruption.  At  the  time  of 
inoculation  there  may  be  more  than  one  point ;  in  fact,  as 
many  chancres  may  appear  as  there  are  points  of  inoculation. 
The  size  and  number  of  chancres  have  no  bearing  on  the 
course  of  syphilis.  According  to  location,  we  divide  chancres 
into  two  classes  :  extragenital  chancres,  as  those  on  lips,  fingers, 
etc. — these  may,  however,  be  gained  by  disgusting  and  un- 
natural practices  in  sexual  relations.  Genital  chancres  are 
those  on  the  genitals  or  the  parts  immediately  surrounding 
the  genitals.  "  Lues  insontium  "  includes  hereditary  syphilis 
and  the  innocently  acquired  genital  or  extragenital  <3hancres. 

Complications  of  Initial  Lesions. — These  are  rare, 
but  may  arise.  Those  of  a  purely  syphilitic  nature — cedema 
indurativum — a  dark  livid  to  brownish  colored  thickening  of 
skin  about  the  lesion.  Again,  the  lymph-vessels  leading  from 
the  chancre  may  become  excessively  hard  and  large.  If  from 
the  glans,  a  lymphangitis  leads  to  a  node  at  the  pubes  which 
may  become  of  hazel-nut  size,  called  "syphilitic  bubonulus." 
Non-syphilitic  complications,  as  phimosis,  paraphimosis,  bal- 
anitis, vaginitis,  and  others,  are  not  uncommon.  Occasionally 
chancres  cause  a  permanent  phimosis.  Again,  if  chancre 
exists  at  the  external  urethral  orifice,  a  stricture  is  readily 
caused. 

Immediately  following  the  primary  sore  the  glands  in  direct 
connection  with  the  lesion  become  enlarged,  usually  within 
one  or  two  weeks,  and  are  characterized  by  being  isolated 
from  one  another ;  hard  and  painless,  and  increased  in  size  : 
if  on  the  penis,  the  inguinal  glands ;  if  on  the  finger,  the 
axillary  glands  ;  if  on  the  tongue,  the  submaxillary  glands. 

The  Differential  Diagnosis  of  Extragenital  Chancres. — To 
this  subject  especial  study  should  be  given.     It  has  usually 


ACQUIRED  SYPHILIS.  23 

been  neglected,  simply  because  too  little  thought  is  commonly 
given  to  the  possibility.  Whenever  a  sore  of  any  kind  occurs 
about  the  lips,  anus,  bearded  face,  finger,  nipple,  or  elsewhere, 
which  has  a  tendency  to  heal  slowly,  one  must  consider  the 
possibility  of  its  being  a  chancre.  In  these  cases  we  w^ll 
usually  find  all  the  glands  of  the  first  aflPected  group  much 
involved,  and  always  still  later  general  adenopathy  occurs. 
The  glands  first  involved  may  be  enormously  enlarged,  and 
again  but  slightly  in  other  cases.  These  glands  have  no  ten- 
dency to  lead  to  suppuration,  and  are  called  indolent  buboes. 
With  the  development  of  the  regionary  glandular  swellings 
the  primary  symptoms  come  to  an  end.  During  the  period 
of  second  incubation  the  multiple  general  adenitis  sets  in. 
Without  any  inflammatory  signs  all  the  glands  of  the  body 
enlarge  painlessly  and  are  of  a  hard  consistence.  If  a  lesion 
having  some  of  the  appearances  of  syphilis  has  been  in  doubt, 
when  this  adenopathy  occurs,  it  clears  up  the  diagnosis. 
During  this  period  general  symptoms  arise,  although  in  a 
large  number  of  cases  they  are  absent,  or  at  least  unob- 
served. They  consist  of  rheumatic  and  neuralgic  pains, 
headaches,  slight  rises  in  temperature,  exaggeration  of  re- 
flexes, enlargement  of  spleen,  anemia,  and  even  icterus. 
The  period  of  second  incubation  ceases  as  soon  as  the  first 
eruption  makes  its  appearance.  As  an  occasional  occurrence, 
really  severe  or  intense  subjective  and  objective  symptoms 
appear  just  prior  to  or  accompanying  the  outbreak  of  the 
eruption.  At  times  this  is  marked  enough  to  simulate  the 
invasion  of  one  of  the  exanthemata,  and  a  differentiation 
must  always  be  carefully  made.  During  any  eruptive  period 
there  is  a  diminution  of  haemoglobin,  a  reduction  in  red  blood- 
corpuscles,  and  an  increase  of  leucocytes.  By  syphilides  or 
syphilodermata,  early  eruptions  and  infiltrations  are  meant. 
By  syphiloma,  the  gummatous  deposits  are  considered.  All 
are  readily  classified  as  follows  : 

I.  Macular :  (a)  Erythematous  ;  (6)  pigmentary ;  (c)  pur- 
puric. 

II.  Papular:  1.  Dr^/ — («)  miliary  ;  (6)  lenticular.     2.  Moist 
— (a)  mucous  patches  ;  (6j  condylomata  lata. 


24  SYPHILIS. 

III.  Pustular  :  (a)  miliary  ;  (6)  lenticular. 

IV.  Tubercular. 

V.  Gummatous. 

I.  Macular  Syphilodermata. 

This  first  exanthem  develops  either  acutely  or  oftentimes 
quite  slowly.  It  may  be  exceedingly  mild  in  character  and 
scarcely  noticeable,  or  it  may  be  very  evident.  It  becomes 
more  prominent  when  the  patient  removes  the  clothing,  being 
due  to  a  change  in  temperature  of  the  body.  It  occurs  usually 
about  the  sixth  week  after  the  appearance  of  the  chancre. 
Then  multiple  round  or  oval  spots  up  to  the  size  of  a  split 
pea,  of  color  varying  from  yellowish-red  to  light-rose  tint  occur. 
Under  pressure  the  color  is  made  to  disappear.  The  abdomen 
best  shows  the  eruption,  but  it  occurs  as  well  over  face,  fore- 
head, neck,  and  extremities.  It  is  never  restricted  to  any 
particular  surface.  In  some  cases  the  macules  may  have  a 
tendency  to  group  themselves.  This  eruption  may  disappear 
without  any  treatment.  A  late  roseola  occurs  in  which  there 
are  larger  efflorescences  grouped,  having  a  tendency  to  scale 
slightly.  Pigmentary  syphiloderm  is  regarded  as  occurring 
Avithout  any  previous  eruption,  and  is  apparently  a  circum- 
scribed loss  of  pigment,  most  commonly  noticeable  in 
women  about  the  neck.  It  consists  of  a  network  of  brown- 
ish colored  pigment.  A  pigment  atrophy  and  hypertrophy 
are  at  the  same  time  going  on.  It  occurs  early  and  is 
persistent,  and  is  not  readily  amenable  to  treatment,  called 
leucoderma.  Purpuric  eruption  occasionally  is  seen,  most 
often  during  the  course  of  mercurial  treatment  or  in  those  of 
low  vitality.  This  eruption  consists  of  small  purplish  spots 
which  do  not  disappear  under  pressure. 

II.  Papular  Syphilodermata. 

These  are  exceedingly  common.  Their  situation,  grouping, 
and  color  are  characteristic.  They  may  follow  a  macular 
eruption,  and  vary  in  size  up  to  that  of  a  silver  ten-cent  piece  ; 
they  may  be  flat  or  conical,  dry  or  moist,  with  color  varying 


PAPULAM  SYPHILOPERMATA.  25 

from  a  dark-red  to  a  ham  color.  This  eruption,  usually  slightly 
scaly,  is  common  on  the  brow,  and  has  received  the  name 
"  corona  veneris."  Whenever  papules  exist  where  surfaces 
come  into  contact  they  commence  to  secrete,  enlarge,  and  be- 
come irritating. 

Dry  miliary  papules  occur  in  patients  whose  general  condi- 
tion is  poor.  They  are  usually  pin-head  in  size,  conical,  some- 
times umbilicated,  symmetrical,  diffusely  arranged,  copper- 
colored,  and  at  the  beginning  may  be  surmounted  by  small 
vesicles  and  later  become  scaly. 

Lenticular  papules,  discrete,  rarely  elevated,  with  the  fore- 
going characteristics,  are  very  common.  These  may  become 
squamous,  and  are  then  termed  papulo-squamous  syphiloder- 
mata.  This  is  the  type  mistaken  for  psoriasis.  Here  the 
scales  are  dirty,  friable,  and  adherent.  This  is  not  uncommon 
on  the  palms  of  the  hands  and  soles  of  the  feet,  being  com- 
monly called  palmar  and  plantar  "  syphilitic  psoriasis." 

Moist  papules  or  mucous  patches  occurring  on  the  mucous 
surfaces  are  flattened  infiltrations  of  varying  sizes,  slightly 
elevated  above  the  adjacent  mucosa,  surrounded  by  an  exceed- 
ingly narrow  band  of  red,  the  surface  covered  with  a  whitish 
or  grayish  film.  They  may  be  single  or  multiple,  and  the 
patches  vary  in  size ;  may  be  red  for  a  time  only,  and  then 
acquire  an  opaline  hue  and  involve  any  part  of  the  mouth  ; 
they  are  usually  painful.  These  may  become  distinctly  eroded, 
of  a  dark-red  color,  and  a  pellicle  may  follow.  If  about  the 
vulva,  a  slight  verrucous  condition  may  appear  after  these 
erosions.  Ulcerative  processes  may  occur,  these  being  exceed- 
ingly common  on  the  tonsils  and  soft  palate;  usually  super- 
ficial and  exceedingly  painful.  Oftentimes,  especially  among 
smokers,  spots  or  bands,  silver  white  and  smooth,  are  seen  in 
syphilitic  patients.  This  leucoplakia  cannot  be  differentiated 
from  the  same  condition  which  may  occur  in  lichen  planus. 
It  is  regarded  by  some  pathologists  as  the  premonitory  step  to 
epithelioma.  A  similar  condition  to  mucous  patches  exists 
also  when  papules  occur  where  surfaces  come  together,  as  be- 
tween the  nates,  and  are  then  called  vioist  papndes.  If  this 
condition  exists  for  any  length  of  time  they  metamorphose. 


26  SYPHILIS. 

and  condylomata  lata  make  their  appearance,  become  disc- 
like, flat  and  warty,  and  give  off  an  offensive  odor  and  a 
thin,  serous  to  seropnrulent,  very  highly  infective  discharge. 

III.  Pustular  Syphilodermata. 

These  usually  follow  papules,  but  may  arise  as  pustules. 
External  application  and  internal  medication  of  various  kinds 
may  be  the  cause  of  the  vesicles,  and  these  in  turn  be  infected. 
They  occur  most  commonly  in  unclean  and  poorly  nourished 
individuals,  are  miliary  in  type,  usually  pin-head  in  size,  and 
then  pass  into  the  lenticular  variety.  These  pustular  syphilo- 
dermata are  again  divided  into  pustulo-crustaceous  or  pustulo- 
nlcerative  syphilodermata.  A  peculiar,  oyster-shell-like  erup- 
tion of  this  type  is  met  with,  and  is  known  as  "  rupia." 

IV.  Tubercular  Syphilodermata. 

Tubercles  may  be  few  or  numerous,  grouped  or  generalized, 
and  are  usually  observed  after  the  second  year  ;  they  are  cir- 
cumscribed, subcutaneous  infiltrations,  reach  the  size  of  a 
large  pea,  or  are  commonly  roundish,  and  the  cause  of  no 
special  symptoms.  They  may  ulcerate  and  become  covered 
with  crusts  or  atrophic  changes  may  occur.  These  tubercles 
may  be  serpiginous  or  "  creeping,"  although  almost  every 
syphilitic  eruption  may  have  this  tendency.  A  vegetating 
type  of  syphilis  is  often  seen  in  the  moist  forms  of  syphilis. 

V.  Gummatous  Syphilodermata. 

When  we  apply  this  term  to  skin  lesions  we  mean  circum- 
scribed nodules,  involving  often  both  skin  and  subcutaneous 
tissue  ;  but  they  may  attack  underlying  tissues.  The  size  is 
variable,  up  to  that  of  a  lemon ;  the  color  of  the  skin  is 
normal,  but  when  breaking  down  is  threatened,  the  color  of 
the  skin  becomes  purplish.  They  are  regarded  as  late  syph- 
ilitic forms,  most  often  localized,  to  one  part  of  the  body. 
When  softening  has  set  in,  a  gummy  discharge  occurs  after 


GUMMATOUS  SYPMILODERMATA.  27 

rupture  of  the  degenerated  area.  Considerable  deformity 
often  remains. 

Any  of  the  appendages  of  the  skin  may  be  involved.  There 
are  two  types  of  loss  of  hair :  one  in  which  the  loss  of  hair 
is  due  to  the  action  of  the  virus  of  syphilis,  probably  upon 
the  nerve-endings ;  and,  secondly,  where  there  is  destruction 
of  the  scalp.  The  first  is  an  early  sign,  and  all  hairs  of  the 
body  may  be  involved,  and  the  alopecia  may  be  diffuse  or 
more  or  less  circumscribed.  Syphilitic  affection  of  the  nails 
and  surrounding  tissue  occurs  :  onychia,  when  changes  are 
limited  to  the  nail  itself,  and  paronychia,  when  involving  the 
substance  about  the  nail. 

The  lesions  appearing  in  the  later  period  of  syphilis  are 
manifold,  although  affections  of  the  eye,  as  iritis  and  periosti- 
tis, are  also  seen  quite  often  in  the  early  months  of  syphilis. 
In  iritis  we  have  a  discoloration  of  the  iris,  cloudiness  of  the 
pupil,  which  is  usually  irregular,  and  severe  hyperemia  of 
the  adjacent  parts.  It  does  not  readily  react  to  light,  and  is 
usually  quite  small,  often  with  pain  in  the  temporal  region. 
The  sight  is  necessarily  impaired.  The  prognosis  is  good  if 
treated  immediately. 

Periostitis  manifests  itself  often  as  nodes,  especially  over 
the  tibiae  and  forehead,  accompanied  by  pain,  and  is  readily 
amenable  to  iodide  of  potassium. 

It  is  impossible  to  enter  into  a  description  of  the  manifold 
affections  in  a  short  review.  Sujfice  to  say  that  syphilis  can 
enter  as  a  direct  or  indirect  factor  in  the  cause  of  disease  of  any 
part  of  the  body.  It  may  completely  destroy  or  impair  the 
function  of  any  organ  of  the  body. 

To  repeat,  it  can  be  stated  that  for  differential  diagnosis  of 
secondary  syphilides — 

(1)  The  larger  number  show  no  acute  inflammatory  symp- 
toms ;  (2)  but  rarely  cause  pain  or  itching ;  (3)  and  are  mostly 
polymorphous. 

Whenever  doubt  of  the  lesion  exists,  the  mucous  mem- 
branes, glands,  and  the  remains  or  the  scar  of  an  initial  lesion 
should  always  be  looked  for  systematically  in  the  regions  of 
possible  occurrence,  both  genital  and  extragenital. 


28  SYFBILIS. 

Prognosis. — In  considering  the  prognosis,  syphilis  must 
always  be  regarded  as  a  grave  and  chronic  disease.  In  no 
instance  is  it  possible  to  state  the  length  of  time  necessary  to 
prevent  any  recurrence.  It  can  be  stated  with  truthfulness  that 
there  is  searcely  any  other  disease  that  is  more  amenable  to 
proper,  persevering,  systematic  treatment  than  syphilis.  As 
cases  of  reinfection  are  known,  it  has  come  to  be  thought  that 
syphilis  is  curable.  At  the  beginning  of  an  attack  the  prog- 
nosis should  be  guarded,  and  later,  after  a  thorough  course 
of  treatment  of  several  years'  duration,  and  then  follovi^ing  a 
period  of  years  without  any  signs  or  symptoms  one  must  be 
hopeful  for  a  complete  cure.  It  is  desirable  to  speak  in 
the  most  favorable  and  hopeful  manner  to  avoid  hypochon- 
driasis and  syphilophobia,  as  fear  and  anxiety  often  cause  these 
conditions.  If  at  any  time  during  the  course  of  syphilis  vital 
organs  are  affected,  it  is  termed  "  syphilis  gravis.^'  If  gum- 
mata  occur  early, — that  is,  during  the  early  secondary  period, 
— it  is  referred  to  as  ^'syphilis gallopans,"  or  " syphilis  maligna^" 

HEREDITARY  SYPHILIS. 

Definition. — Under  hereditary  syphilis  we  regard  all  those 
cases  of  syphilitic  infection  which  exist  previous  to  birth,  no 
matter  whether  any  syphilitic  signs  are  present  at  the  time  of 
birth  or  whether  they  first  appear  at  a  later  period. 

Theories  of  Hereditary  Transmission. — To  illustrate,  take 
the  most  simple  case  :  If  syphilis  is  present  in  both  parents 
or  in  the  mother  at  the  time  of  conception. 

If  the  mother  is  free  from  syphilis  at  the  time  of  impregna- 
tion, we  have  possible  : 

1.  From  the  father,  if  syphilitic,  the  syphilitic  virus  or 
germ,  and  then  theoretically  :  («)  The  mother  at  the  time  of 
conception  becomes  infected  with  the  sperm  a  {syphilis  d' 
embUe).  (6)  The  mother  becomes  infected  during  the  time 
the  living,  from-the-father-infected  foetus  is  in  the  uterus — 
called  ''  choc  en  retour"  (c)  The  mother  during  gravidity  is 
healthy  and  remains  so  ;  but  she  becomes  through  the  pla- 
cental  circulation  of  the  embryo   immune   against  syphilis, 


HEREDITARY  STPfflLLS.  29 

and  can  be  infected  neither  by  the  hereditary  syphilitic  child 
nor  in  any  other  manner  [Colles\s  law).  However,  in  a  much 
later  period  the  mother  may  suddenly  show  tertiary  syphilis 
without  any  previous  symptoms,  and  again  the  mother  may 
remain  immune  only  during  gravidity,  but  become  infected 
at  any  later  period. 

2.  If  both  father  and  mother  are  healthy  at  time  of  con- 
ception, but  if  mother  becomes  affected  during  gravidity  one 
may  have  :  (a)  The  child  may  escape  infection.  (6)  The 
child  may  become  infected  through  the  placenta  and  be 
aborted  or  miscarried,  or  show  positive  signs  of  syphilis  at 
time  of  birth,  or  may  show  signs  of  hereditary  syphilis  at  a 
later  period,  (c)  The  child  may  be  immunized  up  to  the 
time  of  birth  or  longer,  or  may  be  in  other  cases  infected  at 
birth  or  at  a  later  period. 

If  aborted,  it  is  due  to  infection  on  the  part  of  the  mother. 
In  these  cases  syphilitic  changes  can  usually  be  seen  either  in 
the  foetus  or  placenta,  or  both.  Rarely  are  they  entirely 
absent. 

The  more  recent  the  syphilis  of  the  father  or  mother  or 
both,  the  more  certainly  wall  there  be  hereditary  transmission, 
and  the  more  severely  is  the  embryo  affected.  If  both 
parents  are  affected  the  danger  is  greatest.  When  the  mother 
only,  hereditary  infection  is  more  certain  than  when  the 
father  alone  is  infected.  Wherever  these  conditions  exist 
there  has  been  noticed  a  gradual  diminution  of  the  severity. 
At  first  abortions  would  occur ;  then  miscarriage ;  then 
children  at  term,  w^ith  syphilitic  manifestations ;  and,  finally, 
apparently  healthy  children.  Profeta's  law  holds  that 
"  Ilealthy  children  begotten  from  syphilitic  parents  are  immune 
against  syphilis."  This  statement  cannot  be  substantiated. 
Reinfections  upon  hereditary  syphilis  have  apparently  been 
proved. 

The  clinical  appearances  of  hereditary  syphilis  depend 
entirely  on  the  severity  of  the  infection.  In  the  cases  of 
syphilitic  fcetuses  and  children,  visceral  changes  play  an 
important  role.  Changes  in  the  spleen,  liver,  kidney,  pan- 
creas, lungs,  testicles,  and  marked  anaemia  are  not  unusual. 


30  SYPHILIS. 

In  the  more  severe  cases  the  child  may  be  born  too  early 
or  at  term,  and  then  show  grave  nutritive  conditions.  When 
miscarriages  occur,  the  foetus  usually  has  been  dead  for  some 
time,  and  the  skin  is  always  in  a  macerated  condition.  When 
the  child  is  born  the  skin  is  flaccid  and  withered  and  of 
grayish-yellow  tint ;  the  child  has  the  appearance  of  senility, 
with  wrinkles  leading  from  the  angle  of  the  mouth  and  about 
the  nose  and  eyes,  and  is  weazened.  Coryza,  or  "  snuffles," 
pemphigus  syphiliticus  neonatorum,  affecting  especially  the 
soles  of  the  feet  and  the  palms  of  the  hands,  if  not  present 
at  birth,  arise  soon  after.  Certain  exanthemata  occur  which 
have  been  described  under  Acquired  Syphilis.  Besides, 
rhagades  affecting  the  lips,  ulcerating  plaques  in  the  mouthy 
condylomata  lata  about  the  anus,  alopecia,  and  changes  in 
the  nails  may  all  occur.  Bone  affections  are  not  at  all  un- 
common :  circumscribed  periostitis,  dactylitis,  joint-affections, 
and  the  sabre-blade  deformities  of  the  long  bones  are  also 
seen.  Hutchinson  set  up  a  triad  of  stigmata  ;  they  consist  of 
parenohymatous  keratitis,  accompanying  a  sudden  deafness  in 
connection  with  labyrinth  deafness,  and  especially  Hutchinson 
teeth.  These  teeth  occur  variously ;  but  typically  the  upper 
incisors  must  have  crescent-shaped  erosions.  In  addition  to 
these  three  a  choroiditis  is  fi^equently  noticeable. 

Whether  syphilitic  lesions  can  appear  as  late  as  from  the 
seventh  to  the  eighteenth  year  without  having  shown  any 
symptoms  of  syphilis  in  childhood  is  doubted.  Fournier  refers 
to  it  as  "  syphilis  hereditaria  tarda.''  The  question  whether 
or  not  syphilis  can  be  transmitted  to  the  third  generation  is 
questionable.  It  can  at  present  be  stated  almost  positively 
that  there  are  no  known  authentic  cases. 

TREATMENT  OF  SYPHILIS. 

General  Principles. — Since  syphilis  is  recognized  as  a  chronic 
disease,  the  treatment  must  naturally  be  governed  by  this 
fact.  Hence  it  requires  an  extended,  thorough,  and  sys- 
tematic management.  As  cases  vary  from  one  another  they 
must  be,  to  a  certain  extent,  treated  accordingly.     However, 


TREATMENT  OF  SYPHILIS.  31 

it  is  of  prime  importance  to  pay  especial  attention  to  the 
general  health  of  every  patient.  Whenever  an  intercurrent 
sickness  is  present,  this  always  demands  the  proper  atten- 
tion. In  addition  to  this,  it  is  imperative,  for  the  welfare 
of  the  individual,  to  secure  the  best  hygienic  condition.  The 
diet  should  consist  of  plain  but  substantial  food.  Alcoholic 
beverages  should  be  allowed  with  discretion.  The  use  of 
tobacco  in  the  early  stages  should  be  forbidden.  All  the  func- 
tions of  the  body  should  be  kept  active.  The  skin  should  receive 
a  great  deal  of  attention.  Frequent,  in  fact  daily,  warm 
baths,  followed  with  cool  spongings  and  rubbing  with  sea- 
salt,  are  helpful  in  keeping  the  skin  in  perfect  condition. 
The  kidneys  should  be  kept  active  and  the  bowels  should  be 
kept  regular. 

Aims. — In  the  treatment  of  syphilis  we  purpose:  1.  To 
suppress  any  signs  or  symptoms  which  exist.  2.  To  destroy 
the  existing  virus  and  thus  preventing  any  recurrences  of 
infection  and  transmission  by  heredity. 

Abortive  Treatment. — It  is  pertinent  at  this  point  to  ask  : 
"Is  there  an  abortive  treatment  for  syphilis?"  In  other 
words,  can  the  virus  be  prevented  from  entering  the  circula- 
tion? The  large  majority  of  authorities  agree  that  this 
impossible.  However,  it  can  be  stated  that  if  bid  a  few 
hours  intei'vene  after  the  appearance  of  a  lesion,  and  if  easily 
accessible  and  complete  excision  is  allowable,  it  should  be 
done.  It  is  true  that  in  such  a  case  the  correct  diagnosis  is 
not  possible.  But  should  we  wait  ?  In  doing  so  it  will  be 
too  late,  for  the  lymphatics  will  become  invaded.  Should 
the  chancre  be  within  the  urethra  or  at  a  point  where  an 
excision  is  impossible,  thorough  cauterization  with  strong  car- 
bolic acid  (100  per  cent.)  is  to  be  advised.  If  the  lesion  has 
existed  for  some  time,  neither  cauterization  nor  excision  should 
be  practised. 

Specific  Treatment. — In  case  this  abortive  treatment  could 
not  be  instituted,  should  the  specific  treatment  be  commenced 
at  once,  or  should  we  wait  until  the  macnlar  eruption  appears? 
There  can  be  no  denial  of  the  fact  that  it  is  absolutely  wrovg  to 
commence   treatment   until   the   diagnosis  is   positive.     If  the 


32  SYPHILIS. 

diagnosis  of  an  initial  lesion  is  certain,  general  treatment, 
often  called  preventive  treatment,  is  instituted.  It  is  quite 
])ositively  known,  however,  that  it  will  not  prevent,  in  the 
course  of  time,  the  appearance  of  symptoms.  In  some  respects 
it  appears  rational  to  attempt  to  destroy  by  general  treatment 
the  further  ingress  into  the  system  of  the  virus,  yet  experience 
in  a  large  number  of  cases  has  shown  that  it  is  advisable  to  ivait 
for  the  roseola  to  appear.  In  doing  so  we  neither  endanger 
the  patient  in  any  way  nor  interfere  with  the  results  of  the 
treatment  which  is  to  follow.  In  regard  to  the  length  of 
time  required  for  treatment,  again  no  definite  answer  can  be 
given. 

Duration  of  Treatment. — Some  cases  may  require  but  fairly 
mild  treatment  for  three  or  four  years  in  order  to  avoid  any 
further  sign  or  symptom.  Again,  others  may  require  ener- 
getic and  uninterrupted  attention  for  twice  that  number  of 
years.  So  long  as  any  evidences  persist  the  treatment  should 
continue,  and  for  one-half  as  long  again.  It  can,  however,  be 
stated  that  the  course  of  the  disease,  whether  or  not  vital 
organs  are  aflPected,  the  character  and  the  course  of  the  lesions, 
influence  the  mode  and  the  duration  of  the  systemic  treatment. 

Medicinal  Treatment. — This  consists  of  the  imbibition,  by 
the  mouth,  of  remedies — the  so-called  "  internal  treatment ; 
or  applied  externally — the  "external  trecdment.  Besides 
these,  there  are  certain  other  methods.  The  "  tonic "  treat- 
ment consists  of  establishing  for  each  individual  a  maximum 
dosage  of  certain  drugs  which  give  effective  results,  and 
then  to  continue  constantly  for  months  or  even  years.  The 
"  symptomatic  "  or  "  expectant "  plan  consists  in  waiting  for 
the  appearance  of  symptoms  and  then  treating  accordingly. 
This  method  must  be  condemned  in  the  strongest  terms. 
The  "  interrupted  "  jjlan  follows  a  more  or  less  definite  plan 
of  treatment,  covering  a  period  of  years.  External  or  internal 
treatment,  followed  by  varying  periods  of  rest,  with  the  pur- 
pose of  allowing  time  for  the  mercury  to  be  eliminated,  the 
entire  time  covering  some  years,  is  what  is  also  termed  the 
"  chronic  intermittent "  form  of  treatment. 

Mercury  in  some  form,  and  given  in  a  definite  manner,  is 


TREATMENT  OF  SYPHILIS.  33 

the  remedy  and  is  practically  the  sjjecific  for  syphilis.  It  not 
only  causes  symptoms  to  disappear  ;  influences  not  only  the 
virulency  of  the  disease  ;  but  prevents  hereditary  transmis- 
sion. Mercury  is  given  by  the  mouth,  hypodermatically,  or 
by  the  skin.  The  last  way  allows  of  different  methods,  as 
by  rubbings,  baths,  vaporizations,  and  other  methods.  It  is 
ahiiost  the  general  consensus  of  opinion  that  the  hypoder- 
matic or  rubbing  methods  are  energetic  modes  of  treatment. 
Each  has  its  advantage  and  disadvantages,  and  must  be  used 
with  some  definite  purpose  in  view.  Rubbings  are  uncleanly 
and  require  strength  and  also  time  ;  but,  again,  are  usually, 
followed  by  apparently  the  desired  results.  Hypodermatic 
injections  may  be  painful  and  occasionally  followed  by  em- 
boli, abscesses,  and  other  bad  results.  Both  modes,  how- 
ever, avoid  the  stomach,  and  can  be  given  in  those  cases 
where  mercury  would  cause  distress.  Internal  treatment 
often  is  not  followed  with  the  immediate  and  satisfactory 
results  of  other  methods.  Besides,  when  taken  by  the  mouth, 
complications  from  the  gastro-intestinal  canal  arise  more 
easily.  For  these  reasons  one  of  the  methods  of  giving  mer- 
cury is  selected  and  the  chronic  intermittent  treatment  is  then 
begun.  In  the  first  year  at  least  three  or  Jour  such  courses ; 
the  second,  two  or  three ;  and  the  foUoumig  years,  one  or  tioo  ; 
i7iterspersmg  throughout,  internal  treatment.  In  addition  to 
this,  exceedingly  small  quantities  of  iodide  of  potassium  i^howld 
be  given  at  regular  intervals  during  the  first  year,  increasing 
at  stated  intervals  in  the  later  years.  At  least  four  to  five 
years'  treatment  and  an  interval  of  three  years  without  any 
symptoms  or  treatment  whatsoever  must  elapse  before  the 
average  patient  can  be  pronounced  cured.  Even  later,  the 
so-called  ''  prophyla^itic"  treatment,  in  order  to  avoid  any  pos-, 
sible  recurrence,  should  be  regularly  instituted. 

Inunctions. — Official  unguentum  hydrargyrum,  mercury 
vasogen,  mercury  soap,  and  mercury  resorcin — all  50  per 
cent,  of  hydrargyrum — are  the  preparations  to  be  used.  The 
latter  preparations,  however,  are  proprietary  articles,  yet  have 
distinct  advantages.  Usually  from  1  to  8  grammes  (:|-2 
drachms)   daily   are   used.     Definite   parts   of  the   body  are 

9,—V.  D. 


34  SYPHILIS. 

inuncted  for  at  least  twenty  to  thirty  minutes  each  time ; 
best  regularly  at  the  same  time  of  day.  Daily  baths  or  at 
regular  intervals  are  essential.  The  body  should  be  mapped 
out  into  areas  and  no  area  should  receive  a  second  inunction 
before  all  the  others  have  each  been  anointed  once  in  turn. 
Examples  of  such  areas  are  :  neck,  chest,  back,  abdomen, 
loins,  buttock,  thigh,  leg  and  foot,  arm,  forearm  and  hand 
of  each  side,  etc.  It  usually  requires  thirty  to  sixty  inunctions 
for  an  energetic  treatment.  As  a  rule,  at  least  one-half  that 
number  more  of  rubbings  are  required  in  order  to  have  a 
syphilide  disappear.  If  it  requires  thirty,  one-half  more 
would  be  fifteen ;  in  all,  then,  forty-five  rubbings.  This 
mode  of  treatment  may  cause  follicular  dermatitis  and  other 
complications,  which  can,  as  a  rule,  be  easily  treated.  Taylor 
teaches  that  after  having  anointed  each  of  the  above  zones 
once  a  respite  of  a  few  days  before  repeating  the  series  is 
advisable. 

Applications  of  mercurial  plaster  covering  large  areas  of 
skin,  or  putting  mercurial  ointment  in  bags  or  on  lint  and 
placing  about  the  body,  or  using  in  a  pillow,  are  methods 
lately  introduced  (Welander,  Blascho).  In  these  the  mer- 
cury need  not  come  in  contact  with  the  patient. 

The  Hypodermatic  Mode  of  Treatment. — This  has  come  into 
general  use  in  past  years.  Both  soluble  and  insoluble  salts 
of  mercury  and  mercury  itself  are  used.  As  a  rule,  30  to 
50  injections  of  a  1  per  cent,  solution  of  a  soluble  salt  given 
on  consecutive  days  if  no  contraindication  arises  are  used,  and 
again  8  to  12  injections  of  insoluble  salts — one  about  every 
five  days — are  regarded  as  energetic  treatment.  These  injec- 
tions are  given  subcutaneously,  intramuscularly  (then  called 
deep),  or  intravenously.  Some  of  the  more  common  formulas 
used,  subcutaneously,  intramuscularly,  or  intravenously,  are  : 

1^.    Bichloride  of  mercury,       1.0  gramme; 
Sodium  chloride,  6.0  grammes; 

Distilled  water,  100.0         " 


TREATMENT  OF  SYPHILIS.  35 

'Sf.    Cyanide  of  mercury,  1.0  gramme  ; 

Cocaine  hyclrochlorate,     1.0         " 
Distilled  water,  100.0  grammes ; 

These  are  types  of  solution  belonging  to  the  soluble  salts  of 
mevGury.  One  cubic  centimeter  injected  daily  or  every  second 
day. 

I^.    Calomel,  5.0  grammes  ; 

Paraffin  oil,  100.0 

'S^.    Salicylate  of  mercury,       5.0  grammes  ; 
Liquid  paraffin,        '     100.0 

^,    Peptonate  of  mercury,       5.0  grammes  ; 
Sodium  chloride,  5.0         " 

Water,  distilled,  100.0         " 

These  are  types  of  the  insoluble  salts  of  mercury. 

I^.    Bichloride  of  mercury,      5.0  grammes; 
Sodium  chloride,  5.0         " 

Distilled  water,  100.0         " 

The  last  is  a  soluble  salt,  but  is  used  like  the  insoluble 
salts — 1  c.c.  every  five  days. 

Eight  to  twelve  injections  are  regarded  as  sufficient  for  each 
individual  treatment.  Possibly  four  such  courses  the  first,  and 
three  the  next,  and  then  shading  off  in  the  following  years. 

Lang's  gray  oil  is  a  preparation  of  metallic  mercury  with 
lanoline  and  oil.     Of  this,  only  0.1  c.c.  about  every  fifth  day. 

For  intravenous  injections,  and  only  when  mercury  is  im- 
perative, the  following  formula  is  serviceable  : 

^.    Bichloride  of  mercury,      0.1-0.5  gramme  ; 

Sodium  chloride,  5.0         grammes; 

Distilled  water,  1 00.0  " 

1  to  2  c.c.  once  to  twice  daily. 


36  SYPHILIS. 

Fumigations  and  baths  of  soluble  salts  of  mercury  may  be 
of  service  in  individual  cases,  especially  where  there  are 
pustular  or  ulcerative  eruptions,  Avhich  essentially  preclude 
other  cutaneous  applications,  although  they  demand  local 
medication. 

Internal  Medication. — If  mercury  is  given  by  mouth,  one 
should  establish  the  maximum  dose  and  then  continue  until 
symptoms  disappear.  It  is  advisable  to  decrease  the  dose  as 
as  the  indication  arises.  The  remedy  selected  must  give  the 
desired  results,  and  must  not  interfere  with  digestion.  The 
protoiodide  of  mercury  is  the  form  most  extensively  used  in- 
ternally. Occasionally  it  is  necessary  to  give  some  preparation 
of  opium  so  as  to  prevent  diarrhoea,  and  so  that  larger  quan- 
tities can  be  given, 

Protoiodide  of  mercury  in  pills,  each  0.01  to  0.02  gramme, 
and  from  3  to  9  pills  each  day. 

Tannate  of  mercury  in  pills,  each  0.05  to  0.10  gramme, 
and  from  3  to  6  pills  each  day. 

Calomel  in  powders,  each  0.01  gramme,  from  3  to  6  pow- 
ders each  day. 

Gray  powder,  a  mixture  of  mercury  with  chalk,  in  pow- 
ders, each  0.05  to  0.25  gramme,  from  3  to  6  powders  each 
day. 

Throughout  the  course  of  syphilis  the  large  majority  of 
patients  take  with  advantage  some  form  of  iron.  If  mercury 
is  given  internally,  it  may  be  incorporated  with  it.  Bland's 
pills,  or  elixir  of  iron,  quinine,  and  strychnine,  syrup  of 
iodide  of  iron,  are  useful  preparations. 

Sequelae  of  Treatment. — During  the  course  of  any  of  the 
mercurial  treatments  mercurial  stomatitis  and  also  diarrhoea 
may  arise.  Besides,  there  may  be  a  peculiar  mental  depression 
during  which  the  patient  is  restless  and  downcast.  Salivation 
may  be  caused  by  an  idiosyncrasy,  or  the  patient  may  not  have 
observed  cleanliness  of  the  mouth.  When  it  sets  in,  there 
is  a  free  flow  of  saliva;  the  breath  becomes  foetid;  gums, 
tongue,  and  lips  are  swollen  and  bleed  easily ;  the  teeth  ache, 
loosen,  and  may  fall  out ;  and  there  is  a  peculiar  metallic 
taste.      Wlieii  this  condition  sets  in,  it  should  be  remembered  that 


TREATMENT  OF  SYPHILIS.  37 

the  mercury  is  the  cause.  Therefore,  it  must  be  our  object  to 
eliminate  it  as  quickly  as  possible  by  using  general  hygienic 
])rinciples  and  giving  the  mouth  a  great  deal  of  local  atten- 
tion, as  by  the  use  of  mouth-washes  of  peroxide  of  hydrogen 
or  saturated  solution  of  chlorate  of  potassium  ;  or  applications 
of— 

^.    Tincture  of  iodin, 

Tincture  of  myrrh,  of  each,    15.0  grammes. 
Or 

^i.    Ten  per  cent,  chromic  acid  solution. 

Mercurial  dermatitis  occurs  in  some  cases.  Stop  the  ex- 
ternal application  and  treat  with  bland  ointments  or  dusting 
powder.  Folliculitis  readily  follows  in  hairy  individuals. 
In  such  a  case  no  inunctions  are  given  to  these  parts. 

In  addition  to  mercury  there  is  iodine  or  its  jjreparations, 
which  react  especially  in  those  forms  of  syphilis  where  infil- 
trations occur.  This  is  in  the  later  forms  of  syphilis,  and 
consequently  they  have  a  more  limited  use.  However,  the 
symptoms, — often  called  general  symptoms, — as  fever  and 
headache,  react  only  to  iodides.  Again,  when  symptoms  arise 
from  the  bony  or  nervous  systems,  we  must  use  iodine  in 
some  form  in  order  to  get  relief.  In  these  cases  iodide  of 
potassium,  1  gramme  three  times  a  day,  is  to  be  taken  with 
plenty  of  water,  after  meals.  If  this  is  not  sufficient,  the 
dose  can  be  gradually  increased.  Where  destruction  of  tissue 
is  threatened,  as  may  occur  in  the  late  forms  of  syphilis,  even 
so  high  as  10  grammes,  or  more,  may  be  given  three  times 
a  day.  lodipin,  10  to  25  per  cent.,  an  iodine  preparation, 
iodine  vasogen,  6  to  10  per  cent.,  are  more  or  less  useful 
]ireparations.  They  may  be  given  either  by  the  mouth  or 
livpodermatieally,  from  1  to  5  c.c.  once  or  twice  a  day. 
Whenever  there  are  signs  or  symptoms,  even  in  the  earliest 
period,  iodine  in  some  form  should  be  given.  In  an  ordinary 
case  there  is  not  much  need  for  it  in  the  first  year.  However, 
it  should  be  given  in  the  following  years  with  regularity,  even 
if  signs  or  symptoms  are  absent. 


38  SYPHILIS. 

Occasionally  iodinisra  makes  its  appearance  and  the  mucous 
membranes  may  show  symptoms.  Atropine  sulphate  is  then 
to  be  giyen  until  physiological  reaction  follows.  Sulfanilic 
acid,  from  3  to  5  grammes  two  or  three  times  a  day,  has 
given  fair  results  in  some  cases.  In  order  to  work  up  to 
extreme  doses  Starr  recommends  a  saturated  solution  of 
potassium  iodide,  with  an  initial  dose  of  5  to  10  drops,  in- 
creased by  1  drop  each  day  for  one  or  two  weeks,  according 
to  indications  of  tolerance,  then  decreasing  1  drop  each  day 
for  half  this  time,  followed  by  a  regular  series  of  similar 
increases  and  partial  recessions  ;  thus  a  daily  dose  of  500 
drops  can  in  a  few  months  be  established  without  poisoning. 

Mixed  treatment  refers  to  the  imbibition  of  both  mercury 
and  iodine  at  the  same  time.  They  may  be  given  in  the  same 
manner,  or  one  by  mouth  and  the  other  by  inunction,  or  in 
any  other  combination.  This  method  is  usually  desirable  in 
the  later  forms  of  syphilis.  When  given  internally,  mercury 
and  the  iodides  may  be  combined  as  follows  : 

^     Hydrargyri  bichloridi,      0  12  gramme; 

Potassii  iodidi,  10.00  grammes ; 

Tinctures  cinchonse,  30.00         '' 

Elix.  simp.,  q.  s.  ad       120.00  " 

M.  &  Sig. — One  teaspoonful  with  water  after  each 

meal. 

I^     Hydrargyri  bichloridi,       0.05  gramme  ; 

Potassii  iodidi,  10.00  grammes  ; 

Pulv.  liquiritiee,  5.00         " 

Ext.  liquiritise,  q.  s. 
Fiat  massa  et  div.  in  pil.  No.  xxx. 
Sig. — One  pill  after  each  meal. 

Protoiodide  of  mercury  is  virtually  mixed  treatment.  This 
combination  retains  both  the  properties  of  mercury  and  iodine, 
yet  is  usually  given  in  small  quantities  for  very  prolonged 
periods  of  time,  with  the  object  of  preventing  both  secondary 
and  tertiary  changes. 


TREATMENT  OF  SYPHILIS.  39 

In  all  antisyphilitic  internal  medication  it  must  be  boi'ne 
in  mind  that  certain  individuals  -will  accept  it  best  about  two 
hours  after  meals,  when  the  stomach  is  presumably  empty, 
with  a  large  quantity  (at  least  a  tumblerful)  of  water.  Given 
at  other  times  such  persons'  stomachs  will  react  unfavorably. 

Local  Treatment. — It  is  often  necessary  to  treat  the  indi- 
vidual syphilitic  sores.  The  initial  lesion  should  be  kept 
clean  with  1  :  1000  bichloride  of  mercury  solution.  If  this 
is  an  erosion,  it  may  be  covered  with  mercurial  mull  or  with 
calomel.     In  some  cases  mercurial  salve  may  be  desirable. 

Enlarged  glands  are  treated  with  iodine  vasogen  or  iuunc- 
tion  of — 

^     Ung.  potassii  iodidi, 

Ung.  hvdrargyri,     aa   12.5  grammes  ; 

Ung.belladon.,q.s.ad   30.0         " 
M.  &  Sig. — Apply  several  times  daily. 

Again,  hypodermatic  injections  of  mercury  directly  into 
the  glandular  substance. 

Moist  papules  are  to  be  kept  clean  with  bichloride  of  mer- 
cury solution,  and  the  part  covered  with  calomel  or  dusting- 
powder  as  follows  : 

I^     Calomel,  10.0  grammes ; 

Dermatol,  5.0         " 

M.  &  Sig. — Dust  parts  and  keep  them   separated 

with  gauze. 

Plaques  of  the  mouth  require  spraying  with  peroxide  of 
hydrogen,  or  gargling  svith  chlorate  of  potassium  solution,  or 
permanganate  of  potassium,  1  :  5000.  Occasionally  applica- 
tions of — 

^     Bichloride  of  mercury,       1.0  gramme; 

Alcoholis, 

^theris,  aa  50.0  grammes. 

M.  &  Sig. — External  use,  as  directed. 

give  quick  relief. 


40  SYPHILIS. 

As  a  rule,  daily  applications  of  stick  silver  nitrate  bring 
the  best  results. 

In  the  cases  of  syphilomata,  covering  the  parts  with  mer- 
curial ointment  is  almost  necessary  in  order  to  gain  a  good 
outcome. 

When  loss  of  hair  occurs,  applications  of  weak  bichloride 
of  mercury  solution,  1  :  5000,  or  of  ammoniate  of  mercury 
salve,  avail. 

The  treatment  of  hereditary  syphilis  is  practically  the  same 
as  that  of  the  acquired,  using,  of  course,  minimum  doses  and 
gradually  increasing.  In  addition,  the  iodides  may  be  given 
more  freely  in  the  early  period. 

QUESTIONS  ON  SYPHILIS. 

What  is  syphilis  ? 

How  is  syphilis  transmitted  ? 

What  is  the  most  common  manner  of  transmission? 

What  is  the  period  of  incubation? 

Describe  the  course  of  syphilis. 

What  are  the  constitutional  symptoms  of  syphilis,  and  when  do  they  usually 
arise  ? 

Mention  the  most  marked  differences  between  secondary  and  tertiary  le- 
sions. 

What  do  we  mean  by  reinfection ?    Is  it  possible  in  the  case  of  syphilis? 

What  lesions  of  syphilis  are  contagious? 

On  what  does  the  contagiousness  of  the  lesions  depend  ? 

Describe  the  various  appearances  of  the  initial  lesion. 

Can  there  be  more  than  one  "  chancre  "  at  one  time  ? 

What  is  meant  by  "lues  insontium  "  ? 

What  are  the  complications  of  the  initial  lesion? 

What  do  we  mean  by  an  extragenital  chancre? 

What  are  the  changes  in  the  blood  in  the  secondary  stage  of  syphilis? 

What  is  meant  by  syphilides — by  syphilomata  ? 

Describe  the  different  individual  forms  of  syphilitic  eruption. 

What  is  syphilitic  psoriasis? 

What  is  meant  by  leukoplakia? 

Mention  the  more  common  syphilitic  affections  of  the  appendages  of  the 
skin. 

What  are  the  important  features  distinguishing  secondary  syphilitic  lesions  ? 

What  is  meant  by  syphilis  gravis? 

What  is  meant  by  syphilis  gallopans  or  maligna? 

What  is  the  prognosis  of  syphilis? 

What  is  meant  by  hereditary  syphilis? 

How  may  it  be  transmitted  ? 

What  is  syphilis  d'emblee? 

What  is  Colles's  law? 

What  is  Profeta's  law? 

What  is  meant  by  syphilis  hereditaria  tarda? 


CHANCROID.  41 

Is  syphilis  ever  transmitted  to  the  third  generation? 

Describe  the  clinical  course  of  a  syphilitic  conception. 

In  the  treatment  of  syphilis  why  should  the  general  health  he  considered? 

What  do  we  attempt  to  attain  in  the  treatment  of  syphilis? 

Is  there  an  abortive  plan  for  the  treatment  of  syphilis?     If  so,  describe  it. 

Sliould  it  ever  be  instituted? 

When  should  the  systemic  treatment  be  commenced? 

What  is  the  preventive  treatment? 

Is  there  a  definite  length  of  time  for  the  treatment  of  syphilis? 

What  ai'e  the  difl'erent  forms  of  medicinal  treatment? 

Describe  the  diflerent  individual  forms  of  treatment. 

What  is  mercurial  stomatitis? 

How  would  j'ou  treat  it  ? 

What  preparation  is  used  in  the  late  forms  of  syphilis  ? 

In  what  particular  instances  are  the  iodides  valuable  in  the  early  stages  of 
sy[)hilis? 

How  would  you  treat  an  initial  lesion  ? 

How  would  you  treat  a  syphilitic  bubo  ? 

What  is  iodinism,  and  how  would  you  treat  this  condition  ? 

What  is  mixed  treatment? 

How  would  you  treat  mucous  patches  ? 

How  would  you  treat  condylomata  lata  ? 

How  would  you  treat  gummata? 

How  would  you  treat  syphilitic  alopecia  ? 

How  would  you  treat  a  case  of  hereditary  syphilis  ? 

Describe  the  method  of  establishing  tolerance  for  large  doses  of  iodine  in 
severe  cases. 

CHANCROID. 

Definition, — Chancroid  is'a  contagious  disease  of  local  type, 
usually  acquired  during  the  sexual  act.  It  often  occurs  on 
the  genitalia,  although  it  may  appear  on  any  of  the  mucous 
membranes  or  on  any  part  of  the  body.  It  is  never  accom- 
panied by  constitutional  symptoms.  Usually  there  are  sev- 
eral suppurating  and  ulcerating  lesions  which  vary  in  size  and 
appearance.  We  refer  to  these  lesions  as  simple  or  soft  chancre 
or  ulcus  molle. 

Etiology. — Their  cause  can,  at  the  present  time,  scarcely  be 
doubted,  and  the  micro-organism,  as  described  by  Ducrey, 
Unna,  and  others,  can  be  found  in  every  case.  It  is  a  short, 
thick  bacillus,  with  slightly  rounded  extremities,  occurs  often 
in  chains,  sometimes  in  groups,  either  in  the  cells  or  between 
them,  and  is  readily  stained  with  borax-methyl- violet,  methy- 
lene-blue,  or  with  carbol-fuchsin  solution. 

Symptoms. — The  Period  of  Incubation. — This  rarely  lasts 
longer  than  from  one  to  three  days.     The  general  condition 


42  CHANCROID. 

of  the  patient  remains  undisturbed,  and  there  is  complete 
absence  of  fever.  By  contact  and  irritation  severe  pain  can 
be  elicited,  and  frequently  the  pain  is  intense  at  the  time  of 
urination,  if  the  sore  is  within  the  urethra,  on  contact  with 
the  urine,  and  at  time  of  defecation,  if  at  the  anal  opening. 
Usually  within  twenty-four  hours  of  inoculation  a  small 
macule  arises,  and  within  forty-eight  hours  a  pin-point-sized 
vesico-pustule,  surrounded  by  a  reddish  colored  zone,  is  notice- 
able. If  not  subjected  to  maceration  and  irritation,  this 
pustule  in  the  course  of  a  few  days  may  become  the  size 
of  a  split  Lima-bean.  If  the  roof  is  removed,  the  outline 
will  correspond  to  the  size  of  the  pustule  ;  the  edges  are  fairly 
abrupt,  somewhat  steep,  and  have  the  appearance  of  being 
punched  out  with  a  stamp ;  the  floor  is  somewhat  sloughy, 
and  later,  when  repair  sets  in,  has  a  bright  red,  velvety  ap- 
pearance, typical  of  a  granulating  surface.  In  all  cases  there 
are  an  inflammatory  zone  and,  on  the  whole,  more  or  less 
pain,  differing  thus  from  the  initial  lesion  of  syphilis.  When- 
ever, on  account  of  maceration,  there  is  no  pustular  lesion, 
an  erosion  covered  with  thick,  creamy  yellow  pus  is  notice- 
able. The  floor  often  has  a  purplish  hue,  and  the  shape 
of  the  ulcer  is  usually  determined  by  its  location.  Occasion- 
ally the  floor  of  the  ulcer  becomes  elevated  above  the  sur- 
rounding parts,  and  then  we  have  the  so-called  ulcus  elevatum. 
No  matter  what  the  size  of  the  soft  chancre,  the  peculiar 
leathery  hardness  of  the  base  is  almost  always  wanting. 
There  may  be  thickening,  yet  the  characteristic  hardness  is 
always  missing.  Chancroids  may  occur  singly,  but  are  most 
often  multiple.  There  may  be  few  or  very  many.  This  is 
accounted  for  by  the  auto-inoculability  of  the  secretion. 
Their  size  ranges  from  that  of  a  pin-point  to  that  of  a  ten- 
cent  piece,  yet  when  multiple  lesions  coalesce,  areas  the  size 
of  the  palm  of  the  hand  are  occasionally  seen. 

Course,  Sequelae,  and  Complications. — The  average  chan- 
croid, if  uncomplicated,  requires  from  two  to  five  weeks  to 
run  its  course.  A  faint  cicatrix  or  an  ugly  scar  may  remain, 
often  depending  on  the  course  and  the  treatment.  In  the 
male,  a  place  of  predilection  is  along  both  sides  of  the  frsenu- 


COURSE,  SEQUELS,  AND   COMPLICATIONS.  43 

lum  ;  and  on  account  of  loss  of  tissue,  perforation  is  common. 
Within  the  urethra,  at  the  urethral  orifice,  and  also  about  the 
corona,  and  in  the  female,  about  the  labia  or  on  the  vestibule, 
are  places  of  predilection. 

It  is  not  uncommon  to  see  typical  lesions  of  chancroid 
progress  toward  involution,  when  quite  often  one  commences 
to  show  the  appearance  of  an  initial  lesion.  In  the  course  of 
time  syphilitic  symptoms  follow.  This  is  regarded  as  a 
mixed  chancre;  in  other  words,  syphilitic  virus  was  inocu- 
lated at  the  same  time  (or  possibly  later)  as  that  of  the 
chancroid.  Other  complications  are  balanitis,  pldmods,  j^ara- 
phimosis,  vulvitis,  vaginitis,  dermatitis,  and  vegetations.  An 
acute  gangrenous  chancroidal  ulcer  occurs  frequently  when 
constitutional  affections,  such  as  diabetes  or  albuminuria,  are 
present,  or  when  phimosis  or  paraphimosis  occurs.  Phage- 
denic ulcers  are  occasionally  met  with.  Often  all  therapeutic 
measures  have  no  effect  on  their  course.  Probably  the  most 
common  complications  are  lympJiangitis  and  lymphadenitis, 
which,  according  to  some  statistics,  appear  in  as  high  as  25 
per  cent,  of  cases.  As  chancroid  is  a  local  process,  its  virus 
must  remain  at  the  point  of  invasion,  or  confined  within  the 
lymphatics  which  are  in  connection  with  this  point.  If  the 
lesion  is  on  the  penis,  the  dorsal  lymphatic  trunk  is  readily 
palpated  as  an  indurated  and  painful  strand.  At  the  mons 
veneris  there  is  oftentimes  an  enlargement,  which  is  called  a 
bubomdus.  On  either  side  or  on  both  sides  in  the  inguinal 
regions  lymphadenitis  may  arise,  but  generally  only  one  gland 
is  involved.  This  condition  is  termed  bubo,  or  "  blue  ball,'' 
in  common  language.     These  occur  under  diff'erent  forms. 

1.  Simple  Adenitis. — Here  a  small  swelling  and  but  slight 
pain  exists,  with  scarcely  any  redness  to  be  noticed. 

2.  Acute  Suppurating  Adenitis. — Here,  in  the  course  of  a 
few  days,  the  gland  becomes  greatly  enlarged  ;  tenderness 
and  pain  become  marked  ;  fever  may  set  in.  The  gland  often 
becomes  attached  to  the  skin,  and  all  signs  of  inflammation 
appear.  In  some  cases  spontaneous  rupture  occurs,  and 
grayish,  pus-soaked  walls  of  the  abscess  cavity  are  noticed. 
Again,  similarly  appearing  glands,  which    break  down,   are 


44  CHANCROID. 

called  chancroidal  buboes,  because  the  abscess  takes  on  the 
appearance  of  a  chancroid  ulcer,  having  become  infected  with 
the  chancroidal  bacillus. 

3.  Finally,  a  chronic  swelling  of  glands,  where  there  is  but 
slight  or  partial  softening,  which  exists  for  an  indefinite 
period  of  time,  without  any  special  pain  or  tenderness.  This 
is  called  strumous  adenitis. 

Treatment. — The  treatment  of  the  chancroid  depends  on  the 
exact  condition.  If  not  surrounded  by  an  inflammatory  zone, 
a  daily  application  of  Monsel's  solution  is  useful.  At  the 
end  of  about  the  fifth  day  healthy  granulations  will  appear. 
The  application  of  95  per  cent,  carbolic  acid  or  of  50  per 
cent,  chloride  of  zinc  solution  is  followed  by  similarly  favor- 
able results.  Previous  to  any  of  these  applications  a  5  per 
cent,  cocaine  solution  may  be  used  to  anaesthetize  the  parts. 
Between  the  intervals  of  application  nosophen,  aristol,  or 
other  antiseptic  powders  should  frequently  be  applied.  When 
inflammatory  signs,  or  even  complications,  are  present,  ab- 
sorbent cotton  soaked  in  25  per  cent,  copper  sulphate  solu- 
tion may  be  applied  every  four  hours  for  from  fifteen  to 
thirty  minutes  each  time,  for  several  days.  One-half  of  1 
to  2  per  cent,  carbolic  acid  solution,  1  :  1000  bichloride  of 
mercury  solution,  are  useful  in  some  instances.  Between 
applications,  antiseptic  powders  should  be  dusted  on  the  parts 
and  the  opposing  surfaces  separated  with  gauze. 

In  gangrenous  or  phagedenic  ulcers  the  galvanocautery  or 
thermocautery  under  general  anaesthesia  is  almost  imperative. 
In  these  cases  moist  antiseptic  dressings  or  continuous  irriga- 
tions are  indicated.  Iodoform,  if  there  is  no  objection  to  the 
odor,  is  useful  in  the  treatment  of  these  cases.  No  niatter 
lohat  method  is  used  it  is  necessary  to  remove  the  crusts  and  keep 
the  sore  free  from  secretion  at  all  times.  When  destroying 
chancroids  with  caustics,  it  must  be  kept  in  mind  that  occa- 
sionally these  sores  become  intractable  ;  besides,  the  condition 
may  be  aggravated  and  often  obscures  or  makes  correct  diag- 
nosis impossible,  because  all  caustic  treatment  will  cause  more  or 
less  induration.  Whenever  complications  are  present,  surgical 
interference  is  often  necessary — in  cases  of  phimosis,  a  dorsal 


TREATMENT.  45 

incision ;  in  paraphimosis,  the  cutting  of  the  constricting 
band ;  and  in  either  case  the  curetting  of  the  ulcers  is  indi- 
cated, to  be  followed  with  the  usual  antiphlogistic  treatment. 
In  cases  of  simple  adenitis  rest  in  bed,  the  ice-bag,  and  daily 
applications  of  iodine  or  iodine  vasogen  may  abort  and  relieve 
swelling  of  the  gland,  provided  the  ulcer  is  treated  in  a 
rational  manner.  If  the  process  continues,  an  attempt  can 
still  be  made  to  abort  suppuration, 

I^     Calomel,  1.0  gramme; 

Sodium  chloride,  6.0  grammes  ; 

Distilled  water,  100.0        " 
M. 

This  solution  may  be  injected  directly  into  the  glandular 
substance,  1  c.c.  at  a  time.  Necessarily  antiphlogistic  treat- 
ment should  be  continued.  If  fluctuation  arises,  whether  or 
not  any  general  treatment  has  been  instituted,  the  method  of 
Lang  has  come  into  general  use :  A  puncture  is  made,  the 
pus  removed,  and  1  c.c.  of  a  0.25  per  cent,  solution  of  nitrate 
of  silver  injected.  This  treatment  under  a  moist  dressing  is 
continued,  but  the  nitrate  of  silver  solution  is  increased  grad- 
ually to  1  or  3  per  cent.  As  soon  as  the  discharge  becomes 
serous  in  character  the  nitrate  of  silver  solution  injection 
should  be  made  only  every  second  or  third  day.  In  this 
manner  ambulatory  treatment  may  be  given  and  scarcely  a 
scar  remain.  When  the  gland  does  not  pass  on  to  the  point 
of  fluctuation,  but  when  the  suppurative  process  is  present, 
the  gland  may  be  excised  and  the  cavity  treated  with  glutol, 
tincture  of  iodine,  or  other  surgical  applications,  and  packing 
with  antiseptic  gauze  can  be  instituted.  It  is  almost  an 
impossibility  to  remove  any  infected  gland  in  its  entirety  and 
suture  completely  and  get  union.  Suppuration  will  occur, 
and,  as  stated  above,  general  surgical  means  are  then  neces- 
sary. 

Another  very  excellent  treatment  of  single  fluctuating 
glands  is  to  incise  to  a  moderate  extent  only,  evacuate  tlie 
pus,  curette  the  cavity  if  necessary  with  a  small  Volkmann 
spoon,  and  then  fill  the  cavity  with  a  10  per  cent,  solution  of 


46  CHANCROID. 

iodoform  in  pure  glycerine^  suture  the  wound,  and  apply  a 
wet  dressing.  The  results  are  usually  prompt,  complete,  and 
leave  hardly  any  scar. 

DiFFEEENTIAL   DIAGNOSIS  BETWEEN   SYPHILITIC   ChANCEE   AND   SIMPLE 

Venereal  Ulcek. 
Syphilitic  Chancre.  Simple  Venereal  Ulcer, 

1.  Occurs  in  those  who  have  never  had    1.  Maybe  inoculated  repeatedly  with 

syphilis.  this  virus. 

2.  No  positive  germ  recognized.  2.  Bacillus  of  Ducrey  and  Unna  pres- 

ent in  secretions. 

3.  Incubation  between  ten  and  thirty    3.  Incubation  between  one    and  ten 

days.  days. 

4.  The  appearance  of  lesion  varies  as    4.  The  appearance  of  lesion  varies  as 

to  its  site  ;  may  be  rounded   or  to  its  site ;  has  more  or  less  stamped- 

oval ;  usually  but  a  slight  erosion,  out  appearance;  edges  irregular; 

giving  oflf  a  clear  serous  fluid ;  the  covered  "wdth   crust    underneath, 

whole  on  an  indurated  base.    Usu-  which  is  a  yellowish  pus.     Is  auto- 

ally  single,  and  may  appear  any-  inoculable.     Base  most  often  with- 

where  on  the  body.  out    induration.     Secretion    may 

have  an  offensive  odor.  Scar  al- 
most always  remains.  Most  com- 
monly on  genitals. 

5.  May  remain  for  weeks,  but  then    5.  May  persist  for  weeks,  but  is  never 

followed  by  systemic  symptoms.  followed  by  any  systemic  symp- 

toms. 

QUESTIONS  ON  CHANCEOID. 

What  is  a  chancroid? 

Is  it  ever  followed  by  constitutional  symptoms? 

■V^Tiat  is  the  etiologic  factor  ? 

What  is  the  period  of  incubation? 

Describe  the  chancroidal  lesions. 

Are  they  always  accompanied  by  pain  ? 

What  is  the  ulcus  elevatum  ? 

Describe  the  course  of  a  simple  venereal  ulcer. 

How  long  a  time  does  a  soft  chancre  require  to  run  its  course? 

Do  they  leave  scars,  and  if  so,  why? 

What  are  the  places  of  predilection? 

Wliat  is  a  "mixed  chancre"? 

Wliat  are  the  complications  usually  seen? 

What  do  we  mean  by  bubonulus? 

What  is  the  complication  that  is  most  frequently  met  with? 

Describe  the  different  types  of  adenitis. 

What  is  meant  by  a  chancroidal  bubo  ? 

What  is  meant  bv  a  strumous  adenitis? 

Describe  the  different  forms  of  treatment  of  the  venereal  ulcers. 

How  would  you  treat  phagedenic  ulcers? 

How  would  you  treat  simple  adenitis? 

What  is  the  Lang  method  of  treatment  for  adenitis? 

In  which  cases  is  it  necessary  to  treat  surgically? 


PART  II. 
GENITOURINARY  DISEASES. 


GENERAL  CONSIDERATIONS. 

The  urinary  organs  are  connected  anatomically  with  the 
genital  organs.  This  is  especially  true  in  the  male.  They 
consist  of  two  kidneys,  with  two  ureters  which  lead  the  urine 
to  the  bladder.  From  the  last-named  organ  the  urine  is  passed 
through  the  urethra.  Ascending  from  the  bladder  toward 
the  navel,  a  tube,  the  urachus,  usually  obliterated,  exists. 

The  organs  of  generation  in  the  male  consist  of  the  pros- 
tate gland,  seminal  vesicles,  testicles,  epididymes,  vasse  defer- 
entiae,  and  penis. 

The  connection  of  the  urinary  organs  with  the  genitalia  is 
partly  physiological.  Of  the  former,  the  urethra  is  the  outlet 
of  the  product  of  the  organs  of  generation  in  the  male. 

To  understand  the  subject  fully  it  is  necessary  to  note  that 
there  is  a  relationship  between  urinary  diseases  and  the  entire 
organism.  There  are  local  diseases  of  the  organs  without 
any  distant  eifects.  Gonorrhoea  usually  takes  such  a  course, 
but  may  have  most  grave  complications.  Any  chronic  urinary 
or  seminal  disease  may  affect  the  general  condition.  In  the 
course  of  a  gonorrhoea  complications,  especially  from  serous 
surfaces,  are  not  infrequent.  Affections  of  the  joints,  peri- 
cardium, and  pleura  have  been  noted  ;  also  of  the  endocar- 
dium, conjunctiva,  and  rectum.  Besides,  peritonitis  has  been 
positively  established,  and  spinal  irritation  associated  with 
sensory  and  motor  symptoms,  and  also  local  cerebral  symp- 
toms, have  almost  definitely  been  proved. 

Some  of  the  genito-urinary  diseases  are  of  venereal  origin. 

47 


48      GENERAL   COMPLICATIONS  OF   URINARY  DISEASES. 

Many  result  directly  from  the  changes  caused  originally  by 
such  an  infection.  Gonorrhoea  needs  only  mention,  which,  in 
fact,  after  the  gonococcus  is  extinct,  but  where  inflammatory 
symptoms  exist,  may  cause  strictures.  These,  again,  if  severe, 
causing  retention  of  urine,  may  be  the  beginning  of  bladder 
and  later  of  ureteral  and  kidney  diseases. 

Normal  urine  contains  no  germs.  The  normal  urethra 
may,  however,  even  in  health,  be  the  habitat  of  non-patho- 
genic bacteria.  In  all  urinary  diseases  it  is  necessary  to  look 
for  the  cause  of  infection.     It  may  be  : 

1.  Ascending,  from  germs  in  the  urethra,  introduced  into 
the  bladder  by  instrumentation  or  otherwise. 

2.  Descending,  when  kidneys  eliminate  germs,  as  in 
typhoid  fever. 

3.  By  continuity,  whenever  inflammatory  foci  in  adjoining 
parts  affect  the  urinary  organs. 

4.  Metastatic,  whenever  emboli  reach  these  parts. 

It  is  almost  unnecessary  to  state  that  here,  as  elsewhere,  all 
suppurative  inflammatory  processes  are  due  to  germs.  Those 
most  often  found  and  causing  disease  in  the  urinary  and  sexual 
organs  are  the  bacterium  coli  commune,  urobacillus  lique- 
faciens  septicus,  bacillus  of  tuberculosis,  staphylococcus  pyo- 
genes, streptococcus  pyogenes,  and  the  gonococcus. 

QUESTIONS  ON  THE  GENEEAL  CONSIDERATIONS  OF  GENITO- 
URINARY DISEASES. 

Name  the  urinary  organs. 

Name  the  organs  of  generation. 

What  connection  have  these  organs  with  each  other  ? 

Can  urinary  diseases  atFect  the  general  organism? 

Mention  some  complications  of  gonorrhoea. 

Does  normal  urine  in  the  bladder  contain  germs? 

Describe  the  different  modes  of  infection  of  the  urinary  organs. 

W^hat  are  the  most  common  pathogenic  germs  found  in  the  urine? 

GENERAL  COMPLICATIONS  OF  URINARY  DISEASES. 

URETHRAL  FEVER. 

T^rinarji  fever,  urethral  fever,  and  catheter  fever  are  not  un- 
common terms.     They  define  a  peculiar  state  w^hich  follows 


ACUTE  AND   CHRONIC   URETHRAL  FEVER.  49 

instrumentation  or  operation  on  the  urethra  or  the  bladder,  yet 
these  interferences  may  be  of  the  simplest  kind.  What  is 
called  shock  may  follow  the  contact  of  a  sensitive  urethra 
with  an  instrument.  The  patient  may  at  once  become  faint, 
may  lose  consciousness,  become  chilly,  pass  into  convulsions, 
and  exitus  lethaUs — these  may  all  occur  within  a  few  minutes. 
Fortunately,  these  cases  are  exceedingly  rare.  However, 
typical  urinary  infections  are  more  common,  and  Guyon 
divides  them  into  : 

1.  Acute  form,  with  a  single  chill,  fever,  and  sweat,  or, 
where  there  is  a  repetition,  called  by  Thompson  "acute  recur- 
ring urinary  fever ." 

2.  Chronic  urinary  fever. 

I.  Acute  Urethral  Fever. 

Following  operative  interference  on  the  urethra  or  bladder 
the  patient  experiences  usually  within  an  hour  symptoms  of 
an  indefinite  character.  Frequently  after  first  urination  a 
chill,  lasting  from  a  few  minutes  to  hours,  may  set  in.  A  rise 
in  temperature,  headache,  backache,  profuse  perspiration,  then 
a  decline  of  temperature  are  noted.  Within  twenty-four  hours 
all  symptoms  have  passed  away,  but  the  patient  feels  tired. 
At  times  the  chill  is  intense  and  prolonged,  the  skin  cold  and 
cyanotic,  the  breathing  labored,  and  even  slight  delirium  is 
seen.  Again,  the  symptoms  may  be  almost  unnoticeable  in 
character. 

II.  Chronic  Urethral  Fever. 

This  occurs  in  chronic  cases  of  cystitis,  pyelonephritis,  and 
pyelitis.  Here  irregular  chills  and  fever,  or  even  a  contin- 
uous fever,  occur.  In  connection  with  these  symptoms  there 
usually  occur  loss  of  appetite,  dry  and  coated  tongue,  head- 
ache, and  a  variety  of  common  symptoms. 

The  prognosis  in  acute  cases  is  favorable  if  there  is  only 
one  chill,  no  matter  how  severe  the  reaction  ;  in  the  recurring 
type  the  outlook  is  grave. 

Treatment. — Prophylaxis    is    the    most    important — t.  e., 

4— V.  D. 


50      GENERAL  COMPLICATIONS  OF   URINARY  DISEASES. 

asepsis  of  the  field  of  operation  and  instruments.  To  treat 
the  condition,  should  it  come  on,  the  patient  must  be  kept 
warm,  and  efforts  made  to  encourage  free  perspiration.  Later, 
saline  purgatives  are  indicated. 

As  a  prophylactic  treatment  previous  to  instrumental  ex- 
amination or  operation  5  grains  of  quinine  every  three  hours 
for  twenty-four  hours  previous  to  such  procedure  is  advisable. 
After  the  onset,  15  grains  of  salicylate  of  sodium  are  recom- 
mended by  Posner  to  be  given  every  two  hours  for  three  or 
four  times  in  order  to  cause  profuse  perspiration. 

I^      Diuretin,  15.0  grammes; 

AquEe  bullientis,  250.0         " 

Sig. — One  tablespoonful  every  hour. 

This  is  useful  in  order  to  increase  the  activity  of  the  kid- 
neys, as  in  these  cases  there  is  known  to  be  a  suppression  of 
urine. 

A  very  safe  and  certain  abortive  treatment  of  urethral  chills 
in  irritable  subjects  is  to  give  immediately  after  any  instru- 
mentation of  the  urethra  the  following  drugs  :  morphine  sid- 
phate,  0.005  to  0.015  gramme  as  sedative;  quinine  sulphate, 
0.3  to  0.6  gramme  as  antipyretic  ;  and  tincture  of  aconite  0.2 
to  0.4  cubic  centimeter  to  combat  congestion  of  the  kidneys. 
All  should  be  given  at  once.     A  single  dose  is  usually  enough. 

Gonorrhceal  Rheumatism. 

Etiology. — This  is  distinctly  a  complication  of  gonorrhoea, 
occurring  in  both  sexes,  but  most  commonly  in  the  male. 
It  affects  the  joints,  but  the  tendons,  muscles,  and  bursse  may 
become  involved.  In  acute  attacks  of  gonorrhoea  it  arises 
after  the  posterior  urethra  has  become  involved.  Rarely  is 
this  noticed  in  the  first  week  of  a  gonorrhoea.  Of  late  it  has 
been  almost  positively  established  that  the  inflammatory  proc-' 
esses  are  the  result  of  the  action  of  the  gonococcus,  as  they 
have  been  found  in  a  large  number  of  cases  in  the  parts  in- 
volved, and  not  due  to  the  presence  in  the  circulation  of  the 
toxines  or  any  other  pyogenic  bacteria   for  which  the  gon- 


QONOBRHCEAL  RHEUMATISM.  51 

orrhoea  may  have  prepared  the  way.  The  joints  involved, 
and  the  order  of  frequency,  are  the  knee,  ankle,  elbow,  wrist, 
finger,  shoulder,  etc.  In  the  majority  of  cases  more  than 
one  joint  is  involved. 

The  symptoms  may  be  of  a  mild  character,  scarcely  notice- 
able except  for  a  slight  pain  and  stiffness,  or  to  the  opposite 
extreme,  where,  if  one  joint  is  involved,  it  may  become  enor- 
mously swollen  and  painful,  showing  marked  redness  and  ten- 
derness. If  the  eifusion  changes  to  a  plastic  condition,  the 
symptoms  increase  as  a  rule  or  the  disease  may  from  this 
point  on  become  chronic,  with  or  without  relapses.  Occasion- 
ally it  passes  on  to  suppuration.  Naturally  such  symptoms  as 
anorexia  and  pyrexia  intervene  in  the  more  pronounced  cases. 

Differential  Diagnosis. — In  differentiating  from  inflammatory 
rheumatism  it  is  to  be  noted  : 

diffeeential   diagnosis  between  gonorehceal  and  inflammatory 

Eheumatism. 

Gonorrhceal  Eheumatism.  Inflammatory  Rheumatism. 

1.  Gonorrhceal  infections.  1.  No  relation  to  gonorrhoea. 

2.  Usually  a  gonorrhceal  discharge  is    2.  Absence  of  gonorrhceal  discharge. 

present. 

3.  Eheumatic  diathesis  may  be  present    3.  Eheumatic  diathesis  present. 

but  has  no  influence. 

4.  Systemic  symptoms  comparatively    4.  Systemic  symptoms  severe  and  pro- 

mild,  longed. 

5.  Usually  more  than    one   joint  be-    5.  Usually  simultaneous  involvement 

comes     affected,    but    one     after  of  more  than  one  joint, 

another. 

6.  When  painful,  relief  given  by  fix-     6.  Always  pain,  and  fixation  does  not 

ation.     Pain  may  be  absent.  give  relief. 

7.  Cardiac  complications  usually  ab-    7.  Cardiac     complications    frec^uently 

sent.  present. 

8.  Eelapses  common  ;  especially  with    8.  Eelapses  frequent  but  no  relation  to 

a  new  attack  of  gonorrhoea.  urethral  discharge. 

The  more  severe  the  attack,  the  worse  are  the  results. 
Wherever  the  plastic  or  suppurative  process  has  occurred,  it 
is  almost  an  impossibility  to  establish  perfect  motility  again. 

Treatment. — In  these  cases  it  is  of  prime  importance  to 
treat  the  urethra  and  free  it  from  the  gonococcus  and  inflam- 
matory signs,  because  this  is  the  source  and  cause  of  the 
trouble.      The    involved    joints    require    exacting    attention. 


52      GENERAL  COMPLICATIONS  OF  URINARY  DISEASES. 

There  should  be  complete  fixation,  thereby  giving  rest  to  the 
])art.  Cold  lead- water  applications  or,  later,  hot  moist  anti- 
septic dressings  should  be  frequently  applied.  As  soon  as  the 
the  acute  symptoms  have  disappeared,  blistering  with  cups  or 
cantharides  plasters  or  dry  heated  air  and  massage  must  be 
given  in  order  to  cause  the  absorption  of  any  inflammatory 
deposits,  and  thus  prevent  ankylosis.  Internal  medication 
has  no  marked  influence.  However,  if  pain  is  severe,  mor- 
phine must  be  given.  Diluents  and  slightly  alkaline  diuretics 
may  be  given.  Iodide  of  potassium  in  15-  to  30-grain  doses, 
or  ichthyol  in  5-grain  doses,  may  be  given  three  to  five  times 
a  day.  Sodium  salicylate  in  15-  to  60-grain  doses  two  or 
three  times  a  day  may  be  given  in  selected  cases.  Methyl 
salicylate  or  oil  of  wintergreen  may  be  painted  on  the  skin 
over  the  joint  once  or  twice  daily,  ^  to  1  drachm  at  each  appli- 
cation, and  will  be  found  an  excellent  and  reliable  local  analge- 
sic and  resorbent.  The  joint  should  be  wrapped  in  non-absorb- 
ent cotton  after  each  painting  to  stimulate  absorption  and 
local  sweating. 

Haematuria. 

The  presence  of  blood  in  any  form  in  the  urine  is  an  ab- 
solute sign  of  disease  or  injury  of  the  genito-urinary  tract. 
Blood  in  the  urine  is  not  a  disease  per  ne,  but  is  only  a  symp- 
tom. The  quantity  of  blood  may  vary,  and  the  urine  may 
have  the  appearance  of  clear  blood,  may  be  smoky,  or  the 
qnantity  may  be  so  minute  that  it  may  be  found  only  with 
difficulty  by  means  of  the  microscope.  The  appearance  of 
the  blood  often  varies  with  the  origin  :  From  the  kidney,  the 
urine  may  be  smoky ;  from  the  \ireter,  there  may  be  worm- 
like clots ;  from  the  bladder,  irregular,  clotted,  and  often 
scarlet,  and  appears  usually  at  the  end,  occasionally  at  both 
the  beginning  and  the  end,  of  urination ;  from  the  prostate, 
clotted,  with  contour  of  prostatic  urethra ;  from  anterior 
urethra  scarlet,  and  appearing  at  external  urethral  orifice.  It 
was  formerly  believed  that  if  red  blood-corpuscles  were 
crenated  and  had  lost  their  color,  they  signified  origin  in  the 
kidney  or  pelvis  of  the  kidney.     This  is  certainly  an  error. 


PYURIA.  53 

Haemoglobinuria. — Here  there  is  absence  of  the  red  blood- 
corpuscles  but  presence  of  the  coloring-matter;  as  seen  in 
pu rpura  hsemorrhagica. 

Haematuria  is  the  presence  of  blood-corpuscles,  due  usually 
to  inflammatory  diseases  of  the  mucous  membranes  of  urinary 
tract  or  due  to  tumors  or  injuries. 

Pyuria. 

The  presence  of  pus  in  the  urine  is  termed  pyuria.  To 
establisli  the  location  of  its  production  is  one  of  the  most 
important  factors  of  a  correct  diagnosis.  If  not  otherwise 
possible,  the  urethroscopic  and  cystoscopic  examination  may 
reveal  the  location  of  the  disease.  If  necessary  to  make 
the  examination  of  the  urine  from  the  different  kidneys,  the 
ureters  can  be  catheterized  with  one  of  the  different  methods 
in  vogue,  such  as  the  Kelly,  or  with  the  aid  of  the  Nitze, 
Casper,  Brenner,  or  Preston  cystoscope ;  or  the  urine  may  be 
collected  by  separating  the  ureteral  openings  by  a  water-shed 
with  the  Harris  segregator,  and  collecting  the  urine  from  the 
two  kidneys  in  different  containers.  Then  chemical,  physical, 
bacterial,  and  microscopical  examinations  should  be  instituted, 

QUESTIONS  ON  THE  GENERAL   COMPLICATIONS  OF  URINARY 

DISEASES. 

What  is  urinary  fevor  ?     Describe  the  various  forms. 

What  is  the  prognosis  ? 

Give  the  treatment  in  detail. 

What  is  gonorrhoea!  rheumatism  ?     What  joints  may  be  involved  ? 

Is  posterior  specific  urethritis  usually  present? 

By  what  is  gonorrhceal  rheumatism  probably  caused  ? 

Describe  the  diflPerent  types  of  gonorrhceal  rheumatism. 

Which  joints,  in  the  order  of  frequency,  are  most  commonly  affected  ? 

What  is  the  prognosis  ? 

How  would  you  make  the  differential  diagnosis? 

What  is  the  treatment  ? 

What  is  haematuria  ? 

What  is  haemoglobinuria? 

Of  what  is  haematuria  a  symptom  ? 

Of  what  significance  is  blood  in  the  urine  ? 

Is  it  possible  to  recognize  whence  the  hemorrhage  occurs  ?     If  so,  how  ? 

What  is  pyuria? 

How  can  you  locate  the  origin  of  pus  in  the  urine? 

Of  what  significance  is  pus  in  the  urine? 


54      GENERAL  COMPLICATIONS  OF  URINARY  DISEASES. 

DISCHARGES  FROM  THE  URETHRA. 

Spontaneous  Discharges. 

Spontaneous  discharges  from  the  external  urethral  orifice 
can  readily  be  divided  into  these  three  classes  :  1.  Non-puru- 
lent.    2.  Purulent.     3.  Bloody. 

1.  The  non-purulent  discharge  manifests  itself  as  a  sticky, 
stringy,  glairy,  and  light,  grayish-colored  fluid.  Microscopi- 
cally it  is  seen  to  consist  of  epithelial  cells  and  leucocytes, 
but  mostly  mucus.  It  is  called  urethrorrhoea,  and  may  be  seen 
after  a  patient  has  passed  through  a  chronic  urethral  disease. 
When  noticed  after  erection,  in  which  case  it  may  be  physio- 
logical, it  is  called  urethrorrhcea  ex  Ubidine,  and  is  really  due  to 
the  activity  of  the  glands  accompanying  the  congestion  of 
erection.     It  is  a  harmless  condition  in  any  of  its  forms. 

2.  The  purulent  discharges  are  the  most  common.  Here  we 
find  that  the  gonococcus  is  the  most  frequent  cause.  When 
not  due  to  this  organism,  it  is  said  to  be  non-specific  in  char- 
acter. Pus-corpuscles  make  up  the  greater  part  of  the  dis- 
charge, although  a  small  or  large  number  of  variously  shaped 
epithelial  cells  may  be  present. 

3.  The  bloody  discharge  is  characterized  by  the  presence  of 
blood.  It  may  be  due  to  new  growths,  injuries,  or  to  inflam- 
matory processes.  This  discharge  may  be  mixed  with  either 
one  or  both  of  the  aforementioned. 

All  these  discharges  designate  the  process  as  being  located 
in  the  anterior  urethra.  However,  other  processes  posterior 
to  these  may  be  present  at  the  same  time. 

Involuntary  Discharges. 

Another  class  of  urethral  emissions  are  the  involuntary  dis- 
charges Avhich  appear  at  the  external  urethral  orifice  at  times 
of  defecation  or  urination.  These  are  indicative  of  disturbances 
in  the  posterior  urethra.  If  from  the  prostate,  amyloid  bodies 
aud  lecithin  may  be  seen  microscopically.  After  allowing  the 
discharge  to  dry  and  adding  a  few  drops  of  a  1  per  cent,  solu- 
tion of  ammonium  phosphate,  the  well-recognized   Charcot- 


URINARY  EXAMINATION.  55 

Leyden  or  sperma  crystals  are  readily  seen.  If  spermatozoa 
are  noticeable,  the  discharge  must  have  come  from  the  seminal 
vesicles ;  if  all  these  elements  occur,  then  from  both  the 
prostate  gland  and  the  seminal  vesicles  ;  if  pus  in  addition 
is  present,  it  may  come  from  either,  but  spermatozoa  are 
absent  when  it  proceeds  from  the  prostate ;  if  spermatozoa, 
pus,  and  a  few  red  blood-corpuscles,  then  in  all  probability 
the  source  is  the  seminal  vesicles.  If  sperma  from  the  semi- 
nal vesicles  is  passed,  it  often  appears  in  small  sago  or  cylin- 
drical masses  called  the  Bence-Jones  cylinders.  This  last 
condition  is  called  either  defecation  or  mictui^ition  spermator- 
rhosa,  depending  upon  the  time  of  appearance.  If  only  pros- 
tatic secretion,  then  jirostatorrhoea  is  the  scientific  term  for  it. 
Another  discharge  is  the  one  occurring  at  the  time  of  the 
natural  sexual  relations  :  examined  microscopically,  if  the 
spermatozoa  are  non-motile,  it  is  then  called  necrospennia ; 
if  notably  diminished  in  number,  oligospermia;  if  absent, 
aspermia  ;  if  no  ejaculate  whatsoever  has  been  voided  during 
the  coitus,  the  condition  is  spoken  of  as  aspjermatismus. 

QUESTIONS  ON  THE  DISCHAEGES  FEOM  THE  URETHEA. 

What  are  the  spontaneous  discharges  from  the  external  urethral  orifice  ? 

Of  what  significance  are  they  ? 

What  is  meant  by  urethrorrhoea? 

What  is  meant  by  urethrorrhcea  ex  libidine? 

Are  these  conditions  harmless? 

What  is  the  cause  of  the  most  common  urethral  discharge  ? 

What  is  meant  by  involuntary  discharges  from  the  external  urethral  orifice  ? 

Describe  them  microscopically. 

What  is  meant  by  defecation  and  micturition  spermatorrhoea? 

What  is  necrospermia? 

What  is  oligospermia  ? 

What  is  aspermia? 

What  is  aspermatismus  ? 

URINARY  EXAMINATION. 

General  Considerations. 

Thompson  Two-glass  Test. 

For  our  purpose  it  is  of  paramount  importance  to  examine 

and  collect  the  urine,  with  its  products,  from   the  different 

parts  of  the  genito-urinary  tract.     In  a  crude  manner  the 


56  URINARY  EXAMINATION. 

Thompson  two-glass  method  gives  considerable  information. 
If  the  patient  is  allowed  to  urinate  into  two  glasses, — at  least 
60  to  75  c.c.  in  the  first  glass, — it  will  certainly  contain  most 
all  the  urethral  products,  while  the  second  glass  will  contain 
the  urine  as  it  is  in  the  bladder  mixed  with  bladder  and  kid- 
ney elements. 

In  a  simple  case  of  anterior  urethritis  the  contents  of  the 
first  glass  would  be  turbid  and  contain  all  the  secretion,  hat 
IV here  the  latter  is  adherent  it  may  occur  in  the  second  glass, 
which  naturally  gives  rise  to  an  error.  In  order  to  avoid 
this  Jadassohn  advised  the  irrigation  of  the  anterior  urethra 
by  introducing  a  small  Nelaton  catheter  into  the  urethra  up 
to  the  external  sphincter,  and  washing  the  urethra  with  warm 
distilled  water  with  the  aid  of  a  syringe  until  the  wash-water 
passes  perfectly  clear.  Now,  if  the  patient  passes  his  urine, 
it  must  be  absolutely  clear  if  there  is  only  an  anterior 
urethritis.  However,  if  passed  into  two  glasses  after  this 
procedure,  the  first  would  contain  the  posterior  urethral  prod- 
ucts and  the  second  again  the  bladder  and  the  kidney  elements. 

However,  if  after  a  patient  has  held  his  urine  an  hour  the 
first  glass  shows  turbid  and  contains  threads  and  in  the  second 
the  urine  is  clear,  he  is  then  permitted  to  urinate  again  after 
he  has  held  his  urine  for  three,  or  even  more,  hours.  If,  now, 
the  contents  of  the  first  glass  is  turbid,  and  the  second  slightly 
so,  it  at  once  permits  of  a  differential  diagnosis,  provided  the 
turbidity  is  due  to  pus.  It  is  accounted  for  in  this  manner  : 
In  the  first  case  the  time  was  not  sufiicient  for  the  posterior 
urethra  to  secrete  sufficiently  for  the  secretion  to  regurgitate  into 
the  bladder,  as  the  internal  sjjhincter  of  the  bladder  is  much 
weaker  than  the  exteymal  sphincter.  In  the  second  case,  where 
the  interval  between  the  urinations  was  longer,  the  secretion 
passed  into  the  bladder  and  mixed  ivith  the  urine.  Such  ex- 
aminations should  enable  one  to  make  a  differential  diagnosis 
between  p)Osterior  urethritis  and  urethrocystitis.  In  the  latter 
ease  no  matter  how  long  the  interval  between  the  urinations  both 
portions  would  be  turbid. 

Necessarily,  if  purulent  processes  exist  in  the  kidney  or  its 
pelvis  or  in  the  bladder,  all  the  urine  voided  will  be  turbid. 


PHYSICAL  AND  OHeMIOAL  EXAUmATION.  57 

However,  in  case  of  acute  cystitis  or  tuberculosis  of  the 
bladder,  the  urine  passed  into  two  glasses  will  show  the 
second  glass  with  the  greater  turbidity  and  heavier  deposit 
after  standing. 

Posner  Three-glass  Test. 

In  certain  cases  of  posterior  urethral  disease  it  is  advisable 
to  examine  the  urine  by  another  method.  It  is  referred  to  as 
the  Posner  three-glass  method,  and  the  urine  thus  gained  is 
called  expression  urine.  Instead  of  permitting  the  patient  to 
pass  all  his  urine  into  two  glasses  he  is  instructed  to  pass  the 
urine  into  three  glasses,  but  to  stop  after  the  second  glass. 
Then,  by  rectal  examination  and  massage  of  the  prostate  and 
seminal  vesicles,  their  products  are  expressed  either  into  the 
posterior  urethra  or  bladder,  and  the  patient  urinates  into  the 
third  glass.  These  products  are  then  passed  with  the  urine, 
of  course.  For  detailed  information  it  is  necessary  to  examine 
the  sediment  of  this  portion  microscopically. 

To  separate  the  bladder  from  the  kidney  urine  by  voluntary 
voiding  is  impossible.  The  methods  for  this  separation  have 
been  described  elsewhere.  Whenever  the  first  glass  shows 
filaments,  or  so-called  "  go7iorrhoeal  threads,"  and  the  urine  in 
the  second  glass  is  perfectly  clear,  it  can  be  stated  that  these 
threads  arise  in  the  course  of  the  urethra  and  that  no  bladder 
or  kidney  disease  exists. 

Physical  and  Chemical  Examination. 

Whenever  both  portions  of  the  urine  are  turbid  it  is  neces- 
sary to  determine  the  cause.  This  is  readily  done  with  phy- 
sical and  chemical  examinations.  It  may  be  due  to  three 
distinct  conditions  :  (1)  the  mineral  salts  of  the  urine  may  be 
held  in  suspension,  (2)  organic  substances,  such  as  blood  and 
pus,  or  (3)  bacteria,  may  cause  the  turbidity.  The  knowledge 
of  a  few  chemical  facts  is  necessary  for  the  full  understanding 
of  this  valuable  and  practical  method  of  examination  of  the 
urine.  A  small  quantity  of  urine  is  heated,  and  if  the  specimen 
becomes  clear,  the  turbidity  must  have  been  caused  by  urates, 


58  VRINARY  EXAMINATION. 

as  these  are  more  soluble  in  warm  than  in  cold  solutions. 
However,  this  may  or  may  not  occur,  and  instead  the  urine 
may  become  more  turbid,  due  to  a  precipitation  from  solutio]i 
of  some  of  the  phosphates.  On  adding  an  acid  and  causing 
an  acidity  of  the  fluid,  ihe  urine  should  clear  up  if  due  to 
phosphates.  This  turbidity  is  referred  to  as  phosphaturia . 
If  remaining  turbid  after  the  addition  of  acetic,  but  clearing 
up  after  the  addition  of  mineral,  acid,  the  turbidity  must  have 
been  caused  by  oxalate  of  lime,  called  oxalmna.  It  is  need- 
less to  go  into  details,  but,  of  course,  albumin  with  any  of 
these  additions  will  not  clear  up  after  heating. 

Microscopical  Examination. 

Appropriate  tests  will  distinguish  whether  or  not  turbidity 
is  due  to  pus  or  blood. 

Microscopically,  this  can  also  be  distinguished.  Whenever 
the  urine  is  turbid,  and  when,  by  examining  in  a  glass,  a 
peculiar  cloudiness  appears,  apparently  made  up  of  most 
minute  specks,  which  microscopically  is  shown  to  consist  of 
bacteria,  this  is  then  referred  to  as  bacteriuria. 

In  an  epitome  of  the  character  of  this  work  it  is  imperative 
to  omit  further  details  regarding  urinary  examination,  yet  it 
has  been  found  necessary  to  mention  a  few  practical  details  of 
such  procedures.^ 

As  regards  the  cellular  elements  of  the  urine,  it  may  be 
stated  that  in  a  perfectly  normal  urine  epithelial  cells  and 
leucocytes  are  observed.  For  many  years  eiForts  have  been 
made  to  give  descriptions  of  epithelia,  so  that  they  can  be 
recognized  and  the  location  of  their  origin  identified,  but  it 
can  be  positively  stated  that  it  has  not  been  accomplished  up 
to  the  ])resent  time.  Exacting  histological  examinations  have 
shown  that  from  the  exte^'nal  urethral  orifice  to  the  parenchyma 
of  the  kidney  epithelial  cells  of  changeable  forms  are  found. 
This  is  of  especial  importance  and  has  been  recognized  since  the 
metaplasia  of  chronic  inflammatory  conditions  have  been  under- 

^  The  full  data  on  the  examination  of  the  urine  will  be  found  in  the  vol- 
ume on  Urinalysis. 


THE  BACILLUS  TUBERCULOSIS.  59 

stood.  Not  even  cells  of  new  growths  can  he  recognized  unless 
sujftcieyit  structure  be  'present  to  permit  of  diagnosis. 

Filaments  can  readily  be  stained.  With  the  aid  of  a  pipette 
place  them  on  a  slide  and  allow  the  excess  of  fluid  to  be 
taken  up  with  blotting-paper.  Then  dry  thoroughly  and  fix 
by  passing  through  a  flame  with  the  filament  uppermost. 
Place  a  few  drops  of  a  Loeffler's  methylene-blue  solution  on 
the  specimen  for  one  minute,  and  then  wash  out  the  excess  of 
coloring-matter.  Dry  and  examine  directly  with  oil-immer- 
sion lens.  In  this  manner  the  gonococcus  and  other  bacteria 
may  readily  be  found,  and  also  the  outlines  of  cellular  ele- 
ments shown. 

Whenever  distinct  masses  of  debris  or  coagula  or  particles 
jiassed  with  the  urine  are  examined,  this  should  first  be  done 
without  any  attempt  at  staining,  the  particles  being  teased  and 
then  covered  with  a  cover-glass.  If  deemed  necessary,  other 
particles  can  be  hardened  and  prepared  and  treated  in  the 
same  manner  as  other  pathological  specimens — cut  in  paraffin 
and  stained  as  desired.  This  frequently  is  of  great  value. 
Then  coagula  and  masses  can  be  examined  for  any  definite 
structure. 

The  Bacillus  Tuberculosis. — Besides  the  gonococcus  there  is 
one  other  kind  of  bacterium  which  is  of  the  greatest  impor- 
tance in  this  field  of  work.  It  is  the  bacillus  tuberculosis. 
Many  methods  are  used  for  staining.  If  necessary,  the 
specimen  of  urine  should  be  centrifugaiized,  or  the  specimen, 
which  in  some  cases  of  disease  of  the  prostate  and  seminal 
vesicles  passes  from  the  external  urethral  orifice,  after  massage 
of  these  parts  should  be  placed  on  a  cover-glass,  and  dried 
and  fixed  in  the  usual  manner.  It  should  "then  be  placed 
for  ten  minutes  in  a  solution  of — 

I^      Fuchsin,  1.0  gramme ; 

Alcohol  (95  per  cent.),  10.0  grammes ; 

Carbolic  acid  (95  per  cent.),     5.0         " 
Distilled  water,  100.0         " 

Then  thoroughly  washed,  dried,  and  allowed  to  remain 
in  a  solution  of — 


60  VRtNARY  EXAMINATION. 

I^     Metliylene-blue,  2.0  grammes ; 

Sulphuric  acid,  25.0  " 

Distilled  water,  100.0 

until  the  specimen  is  of  a  sufficiently  blue  color  and  then 
dried  and  mounted  in  Canada  balsam.  The  bacillus  tubercu- 
losis appears  red ;  all  else  blue. 

Weichselbaum's  method  for  staining  for  the  bacillus  tubercu- 
losis is  especially  adaptable  for  urinary  sediments,  as  smegma 
bacilli  lose  their  stain  and  can  therefore  not  be  mistaken  for 
them.  The  specimen  is  stained  in  the  regular  manner  with 
fuchsin  solution,  then  decolorized  in  absolute  alcohol,  and 
then  counterstained  with  an  aqueous  methylene-blue  solution. 

With  the  aid  of  culture-media  and  the  injection  of  urine 
into  animals  we  have  additional  means  in  important  cases  of 
deciding  as  to  the  character  of  the  infection. 

It  is  well  to  know  what  the  relative  number  of  pus- 
corpucles  in  a  cubic  centimeter,  when  counted  with  a  Thoma- 
Zeiss  counting  apparatus,  is :  In  light  attacks  of  cystitis 
there  are  about  25,000  corpuscles  to  each  cubic  centimeter ; 
100,000  in  the  severe  cases.  Whenever  the  former  are  pres- 
ent it  represents  1  to  1000  of  albumin,  estimated  with  the 
Esbach  albuminometer.  In  other  words,  this  amount  of  albu- 
min is  derived  from  the  pus  and  corresponds  to  this  number 
of  pus-corpuscles  in  each  cubic  centimeter.  If  we  would 
have  3  to  1000  albumin  and  25,000  corpuscles,  it  would  indi- 
cate that  the  excess  of  albumin  is  derived  from  some  other 
source  :  that  it  is  not  serum-albumin  from  the  corpuscles, 
but  from  the  kidneys. 

It  need  scarcely  be  emphasized  that  every  means  of  ex- 
amination of  urine  which  may  help  in  establishing  a  correct 
diagnosis  of  urinary  diseases,  especially  where  operative  inter- 
ference on  one  kidney  has  become  necessary,  is  of  vital  im- 
portance in  certain  cases. 

METHODS  TO  ESTABLISH  THE  EFFICIENCY  OF  THE 
KIDNEYS. 

Cryoscopy. — In  order  to  establish  the  "  sufficiency  "  of  the 
activity  of  the  kidneys,  Koranyi  lately  introduced  a  physical 


QUESTIONS  ON   URINARY  EXAMINATIONS.  61 

method  of  examination.  This  depends  entirely  on  the  fact  that 
the  laws  of  osmotic  pressure  show  that  solutions  of  different 
concentration  have  also  different  volatilizing  and  freezing- 
points.  Both  become  proportionately  lower  as  the  concentra- 
tion increases.  The  sinking  to  the  freezing-point  of  an  aqueous 
solution  of  a  salt  under  that  of  distilled  water  is  directly  pro- 
portionate to  the  amount  of  dissolved  molecules.  With  this 
method  the  freezing-point  of  urine  has  given  valuable  infor- 
mation as  regards  its  concentration,  and  hence  in  this  manner 
it  can  show  the  activity  of  the  kidneys.  This  method  is  called 
cryoseopy. 

The  phloridzin  test  is  another  method  to  establish  the  suffi- 
ciency of  the  kidneys.  Phloridzin,  0.005  gramme,  is  injected 
subcutaneously.  It  depends  on  the  property  of  phloridzin  to 
cause  sugar  to  appear  in  the  urine.  Diseased  kidneys  do  not, 
or  but  very  slowly,  allow  the  excretion  of  sugar.  Hence  if 
urine  is  collected  separately  from  the  two  kidneys,  some  idea 
as  to  the  soundness  of  the  kidneys  can  be  established. 

Methylene-blue  has  also  been  used  as  a  test.  This  depends 
on  the  coloring-matter  passing  the  kidney.  In  healthy  kid- 
neys, after  taking  a  few  grains  of  methylene-blue  by  the  mouth, 
the  urine  can  be  observed  to  escape  from  the  ureters  with  the 
aid  of  a  cystoscope,  or  collected  separately  with  the  various 
methods  described.  If  healthy,  it  usually  requires  from  fif- 
teen to  twenty  minutes.  The  severer  the  affection,  the  longer 
time  does  it  require  for  the  colored  urine  to  appear  from  the 
ureters  from  the  kidneys. 

QUESTIONS  ON  UEINAEY  EXAMINATIONS. 

Describe  the  Thompson  two-glass  method  for  the  examination  of  urine. 

Of  what  significance  is  it? 

Of  what  value  for  diagnostic  purposes  is  it  to  irrigate  the  anterior  urethra 
until  the  wash-water  is  free  from  all  specks  and  threads,  and  then  to  allow  the 
patient  to  pass  urine  into  two  glasses  ? 

In  which  class  of  cases  is  the  Thompson  two-glass  method  of  no  value? 

What  is  meant  by  the  Posner  three-glass  method  for  the  examination  of  urine  ? 

Why  should  a  specimen  be  passed  into  a  third  glass?  What  information 
does  it  give  ? 

Is  it  possible  to  separate  the  urine  in  the  bladder  from  the  urine  as  it  comes 
from  the  kidney  by  voluntary  voiding  ? 

If  the  entire  quantity  of  urine  passed  is  turbid,  to  what  conditions  may  it 
be  due? 


62        ABNORMALITIES  IN  THE  ACT  OF  URINATION. 

How  are  they  differentiated  from  each  other? 

Are  there  in  a  normal  specimen  of  urine  any  cellular  elements  ? 

Is  it  possible  to  recognize  by  shape  or  size  the  point  in  the  genito-urmary 
tract  whence  the  epithelial  cells  come?     Why  not? 

How  would  you  stain  a  filament? 

Is  it  possible  to  make  sections  from  sediments  consisting  of  debris  in  the  urme  ? 

Is  the  Bacillus  tuberculosis  ever  found  in  the  urine? 

How  would  you  examine  for  it? 

Describe  the  different  staining  methods. 

If  not  found  in  this  manner,  is  it  possible  to  decide  their  presence  or  absence 
in  any  other  manner? 

Of  what  value  is  it  to  know  that  we  have,  for  example,  100,000  pus-cor- 
puscles in  each  cubic  centimeter  and  4  to  1000  albumin  estimated  with  the 
Esbach  albuminometer? 

Why  is  it  necessary  to  examine  the  urine  so  thoroughly  previous  to  any 
operative  interference? 

What  is  meant  by  cryoscopy? 

What  does  it  establish  ?  i.t  x.     x. 

What  are  the  phloridzin  and  methylene-blue  methods  to  establish  the 
"  sufficiency"  of  the  kidneys?     Describe  in  detail. 

ABNORMALITIES  IN  THE  ACT  OF  URINATION. 

NORMAL  MICTURITION. 

The  functions  of  the  bladder  practically  consist  of  hold- 
ing and  voiding  the  urine.  The  former  is  controlled  by  two 
muscles — i.  e.,  the  internal  and  external  sphincters  of  the 
bladder.  If  these  were  paralyzed,  there  would  be  constant 
dribbling.  If  a  spastic  condition  affected  these  muscles,  the 
opposite  condition,  or  retention  of  urine,  would  result.  Now, 
in  voiding  urine  the  detrusor  muscles  of  the  bladder  contract, 
while  at  the  same  time  there  is  a  relaxation  of  the  sphincter 
muscles.  In  addition,  there  is  abdominal  pressure,  aided  by 
the  movement  of  the  diaphragm,  and  finally  the  hydrostatic 
pressure  also  takes  part. 

Some  physiologists  believe  that  the  sensation  of  urination 
is  centered  at  the  internal  urethral  orifice  or  at  the  internal 
sphincter  muscle.  Therefore  the  desire  to  urinate  comes  from 
the  attempt  of  this  muscle,  by  constant  contraction,  to  with- 
stand the  expulsion  of  the  urine  by  the  detrusor  muscles  as 
soon  as  it  becomes  irritated  by  the  quantity  of  urine  in  the 
bladder — that  is,  this  causes  the  sensation  of  urination.  Now, 
after  the  internal  sphincter,  an  involuntary  muscle,  relaxes, 
the  urine  passes  into  the  posterior  urethra — into  the  so-called 


ABNORMAL   MICTURITION.  63 

nech  of  the  bladder.  As  the  quantity  of  urine  increases  the 
desire  to  urinate  continues  to  increase.  When  the  entire 
quantity  becomes  so  large  that  pain  or  other  sensations  are 
caused,  the  individual  allows  the  external  muscle,  which  is 
partly  voluntary,  to  become  lax,  and  the  act  of  urination  sets  in. 

ABNORMAL  MICTURITION. 

There  are  two  abnormalities  which  must  be  considered : 
1 .  The  frequency  of  urination.  2.  The  pains  accompanying 
the  act  of  urination. 

Now,  in  pathological  conditions  the  changes  in  the  muscles 
which  permit  the  act  of  urination  come  on  more  frequently 
and  more  rapidly.  Take  an  irritation — an  ulcer,  stone,  in- 
flammation— at  the  neck  of  the  bladder.  This  will  cause 
the  muscles  to  act  more  quickly  and  more  forcibly.  The 
constantly  irritated  and  contracting  sphincter  becomes  tired 
and  gives  way  more  easily,  and  the  voluntary  external  sphinc- 
ter is  called  into  use  oftener. 

The  exact  number  of  times  of  urination  and  the  length  of  the 
intervals  shoidd  be  elicited.  This  is  of  as  much  importance  as 
the  quantity  of  urine  voided  each  time.  In  cases  of  diabetes 
insipidus,  where  enormous  quantities  are  passed  frequently,  it 
would  be  an  aid  to  diagnosis  at  once.  However,  if  a  patient 
urinates  frequently,  because  large  quantities  are  voided  each 
time,  he  scarcely  waits,  and  does  not  allow  the  desire  to 
become  strong.  But  whenever  the  pathological  condition  is 
in  the  neck  of  the  bladder,  this  imperative  desire  sets  in  more 
rapidly.  Patients  complain  about  the  intensity,  and  if  it 
becomes  severe,  then  it  is  referred  to  as  tenesmus.  What  are 
the  conditions  that  cause  this  ?  They  can  readily  be  seen.  In 
chronic  cases  of  inflammatory  diseases  the  condition  is  not  so 
apparent,  yet  it  is  present.  It  is  in  acute  diseases,  as  in  acute 
posterior  urethritis  involving  the  prostate  or  in  tuberculosis 
of  this  area,  that  the  tenesmus  is  almost  constant.  Polyps 
located  at  the  external  urethral  opening  may  cause  it.  Rest 
relieves  this  condition  and  exercise  irritates  it.  In  cases  of  hyper- 
trophy of  the  prostate  there  may  be  normal  urination  during 
the  day,  but  an  iijcreased  number  of  times  during  the  night. 


64        ABNORMALITIES  IN  THE  ACT  OF  URINATION. 

Under  another  division,  classified  as  neuroses,  there  are 
diversified  conditions  causing  the  same  symptoms.  In  cases 
of  a  stone  in  the  pelvis  of  the  kidney  there  is  this  symptom 
of  frequent  urination  apparently  both  day  and  night.  In 
neurasthenics  or  in  former  masturbators,  where  there  are 
irritable  conditions  of  the  neck  of  the  bladder,  this  again  is 
not  uncommon.  Even  if  patients  give  themselves  rest,  this 
symptom  of  frequent  urination  exists  both  day  and  night. 

Pain  during  the  act  of  micturition  is  of  great  importance, 
often  closely  associated  vi^ith  tenesmus,  but  tenesmus  is  not 
necessarily  associated  with  pain.  With  the  aid  of  these 
symptoms  we  attempt  to  locate  their  origin  and  show  their 
significance.  This  is  done  by  the  time  referable  to  the  act  of 
urination.  Whenever  tenesmus  is  absent,  the  pain  can  exist 
only  during,  or  it  accompanies  or  follows,  the  act  of  urination. 

In  acute  anterior  gonorrhoea  the  pain  is  probably  caused  by 
the  stream  of  urine  forcing  its  way  through  the  swollen 
urethra,  and  therefore  exists  only  during  the  act  of  urina- 
tion. Hence  there  is  no  pain  before  or  after  the  act.  Here 
the  trouble  lies  in  the  urethra. 

Again,  if  a  patient  complains  of  tenesmus  and  pain  almost 
shnulto.neously ,  and  if  they  continue  during  the  voiding  and 
disappear  at  the  end  of  the  act,  the  probable  cause  is  a 
bladder  affection — for  instance,  an  acute  cystitis. 

If  pain  exists  before  and  during  urination  and  increases 
after  the  act,  there  may  be  several  possibilities.  In  all  acutely 
inflammatory  disturbances  of  the  prostate  pain  occurs  in  this 
manner  and  sometimes  with  stone. 

Not  an  unusual  complaint  in  urinary  disease  is  pain  hetiveen 
the  intervals  of  urination.  A  dull  ache  in  the  suprapubic 
region  may  be  significant  of  a  bladder  disease.  Pain  in  the 
rectum  and  occasionally  radiating  down  the  thighs  may  indi- 
cate prostatic  disease.  Pain  in  the  perineum  may  indicate 
periprostatic  disturbances. 

Dribbling  of  urine  after  urination  is  most  commonly  caused 
by  stricture,  although  it  may  be  due  to  nervous  conditions. 
In  the  latter  cases  we  find  masturbators  or  individuals  with 
incipient  spinal  diseases,     Whenever  this  dribbling  becomes 


ABNORMAL  MICTURITION.  65 

worse,  so  that  the  stream  is  passed  only  in  drops  ;  where  there 
is  slight  pain  during  the  act ;  and  where  there  is  a  scanty  dis- 
charo-e,  the  diagnosis  of  stricture  is  almost  positive.  In  these 
spinal  affections  there  may  be  either  complete  retention  or 
incontinence.  In  prostatic  hypertrophy  acute  retention  may 
also  set  in,  and  whenever  retention  does  appear  occasionally 
dribbling  may  occur.  If  so,  it  is  an  overflow,  the  bladder 
being  unable  to  hold  any  more,  and  is  not  a  true  incontinence, 
hence  called  "  paradoxical  incontinence." 

Involuntary  urination,  as  is  common  in  children,  especially 
during  the  sleeping  hours,  is  referred  to  as  enuresis  nocturna. 
Whether  or  not  it  is  due  to  imdeveloped  muscular  tissue  is 
not  definitely  known.  Enuresis,  however,  may  be  caused  by 
psychical  disturbances. 

If  a  patient  does  not  urinate  it  is  due  either  to  retention  of 
urine,  caused  by  an  obstruction  to  the  outflow,  or  to  a  par- 
alysis of  the  detrusor  muscles,  with  or  without  the  accom- 
panying spasm  of  the  sphincters,  or  to  some  form  of  anuria. 

In  kidney  affections  there  are  often  pains  in  the  lumbar 
region,  even  radiating  into  the  testicles.  Whenever  pain, 
usually  colicky  in  character  and  accompanied  by  general 
symptoms  of  great  severity,  is  caused  by  stone  passing  from 
kidney  down  the  ureter,  it  is  referred  to  as  "  renal  colic." 

There  are  comparatively  few  diseases  of  the  urinary  tract 
which  are  not  accompanied  by  pain.  Of  these,  atonic  con- 
ditions of  the  bladder  are  examples. 

The  intensity  or  the  force  of  the  stream  as  it  comes  from 
the  bladder  is  of  significance.  It  is  influenced  either  by 
changes  in  the  muscular  structure  of  the  bladder  or  by  some 
mechanical  impediment  to  the  stream  in  the  course  of  the 
urethra.  They  may  be  so  great  as  to  vary  from  a  stream  witli 
intense  force  to  one  that  scarcely  flows  from  the  external  urethral 
orifice,  or  again  to  where  the  urine  escapes  only  by  drops. 

If  wine  in  the  bladder  cannot  be  passed,  the  condition  is  called 
retention.  It  may  be  due  to  acute  inflammatory  diseases,  to 
obstruction,  or  to  paralysis  of  the  detrusor  muscles,  as  it  occurs 
in  spinal  diseases. 

The  form,  size,  and  direction  of  the  stream  are  influenced 

5— V.  D, 


m        ABNORMALITIES  IN  THE  ACT  OF  URINATION. 

to  a  large  extent  by  the  external  urethral  orifice,  hence  but 
little  weight  should  be  given  to  abnormalities. 

If  no  urine  is  collected  in  the  bladder,  and  therefore  none 
voided,  it  must  be  because  the  kidneys  do  not  secrete  any. 
This  condition  is  called  anuria. 

A  tabulated  review  is  as  follows  : 


a  .2 


The  length  of  time 
between  the  acts,  and 
gives  rise  to — 

The  length  of  time  as- 
sociated with  the  act, 
and  gives  rise  to — 


^   i 


The  effort  necessary  for 
the  performance  of  the 
act,  and  gives  rise  to — 


The  sensation  attend- 
ing the  act,  and  gives 
rise  to  pain  as  follows : 


Increased  frequency  of  micturition. 

Diminished 

Eetention. 

Overflow. 

Irrepressible  micturition. 

Urgent 

Eetarded 

Interrupted 

Diificult  micturition. 

Obstructed 

Incontinence  of  urine. 

False  incontinence. 

Involuntary  micturition. 

Unconscious 

Painful  micturition : 


Time  of  sensation 


Seat  of  sensation — 
direct  and  reflex 


before. 

during. 

after. 

hypogastrium. 

bladder. 

perineum. 

rectum. 

glans  penis. 

elsewhere. 


•Characteristics  of  the 
stream  modified  ^s  to 

its— 


r  increased 


I  feeble  stream, 
perpendicular, 
dribbling, 
slobbering. 

f  increased  size. 
I  diminished  size 

( oval. 
]  flat, 
i  spiral, 
f  bifurcated. 
Direction  I  radiating, 
(deflected.. 


Force 


Size 


Form 


GENITO-UBINARY  INSPECTION  AND  PALPATION.      67 

QUESTIONS  ON  THE  ACT  OF  URINATION. 

What  is  the  physiology  of  the  bladder? 

Explain  the  mechauism. 

How  is  the  sensation  of  urination  derived  ? 

What  are  the  two  most  common  abnormalities  in  the  act  of  urination  ? 

What  symptoms  would  an  ulcer  at  the  neck  of  the  bladder  cause? 

Why  should  the  quantity  voided,  and  the  number  of  times  of  urination,  be 
elicited? 

What  is  tenesmus  ? 

In  what  class  of  cases  is  there  usually  tenesmus  ? 

In  what  class  of  cases,  and  enumerate  some,  does  rest  give  relief  from  ten- 
esmus? 

In  what  class  of  cases,  and  enumerate  some,  do  we  find  that  rest  does  not 
alleviate  the  desire  to  urinate,  neither  by  day  nor  night? 

In  what  manner  is  pain,  referable  to  urination,  of  importance  ? 

Eeferable  to  the  act  of  urination,  when  do  we  have  pain  ? 

When  is  there  pain  in  acute  anterior  gonorrhoea? 

Describe  the  character  and  the  time  of  pain  in  an  acute  inflammation  of 
the  bladder. 

In  acute  prostatic  diseases,  when  is  there  pain  ? 

Is  there  ever  pain  in  the  intervals  of  urination? 

What  diseases  do  they  accompany  ? 

Are  there  urinary  diseases  ever  unaccompanied  by  pains? 

Of  what  significance  are  the  force,  size,  form,  and  direction  of  the  stream  of 
urine  ? 

In  what  ways  are  these  conditions  influenced  ? 

What  is  meant  by  retention  of  urine? 

By  what  may  it  be  caused  ? 

Has  dribbling  after  urination  any  significance  ? 

If  urine  can  be  passed  only  by  drops,  does  it  signify  anything  in  particular? 

What  is  meant  by  "  paradoxical  "  incontinence  ? 

Does  involuntary  urination  ever  occur? 

What  is  enuresis  nocturna? 

Whenever  urine  is  not  voided,  to  what  may  it  be  due? 

What  is  meant  bv  anuria  ? 


GENITO-URINARY  INSPECTION  AND  PALPATION. 

In  the  routine  of  examination,  after  the  discharge  and  urine 
have  been  examined,  the  physical  examination  correctly  fol- 
lows, although  in  daily  work  oftentimes  it  precedes  the  others. 

First  of  all,  malformations  of  the  genitalia  are  to  be  ob- 
served: hypospadias,  epispadias,  openings  about  the  urethral 
orifice,  or  other  congenital  affections. 

During  inspection  the  penis  is  the  first  to  be  examined  and 
the  presence  or  absence  of  inflammatory  signs  at  the  external 
urethral  orifice  noted.  Lymphangitis,  appearing  as  red  bands 
along  the  dorsum  of  penis,  and  signs  of  inguinal  adenitis, 


68        ABNORMALITIES  IN  THE  ACT  OF  URINATION. 

edema  of  foreskin,  phimosis,  paraphimosis,  balanitis,  posthitis, 
and  balanoposthitis  can  all  be  readily  diagnosed. 

Swellings  or  tumors  involving  the  penis,  as  condylomata 
lata  or  acuminata ;  enlargements  of  the  scrotum,  such  as 
hydrocele,  varicocele,  orchitis,  epididymitis ;  affections  of  the 
skin,  fistula  of  the  urethra,  bladder,  or  kidneys,  urinary  infil- 
trations, bulging  of  the  perineum,  or  above  the  pubes  or  in 
the  lumbar  regions  must  be  noted.  Occasionally,  in  retention 
of  urine,  there  is  a  marked  bulging  of  the  suprapubic  region. 
In  ectopia  of  the  bladder  there  is  absence  apparently  of  the 
anterior  wall,  and  the  ureteral  openings  may  readily  be  seen 
on  the  parts  of  the  bladder  exposed. 
-  It  is  obvious  that  lohat  is  seen  must  he  verified  by  pal- 
pation in  order  to  substantiate  the  findings.  Tumors  of  the 
external  genitalia  can  readily  be  felt.  Those  of  the  testicle 
and  epididymis  are  quite  common.  Along  the  course  of  the 
urethra  fluctuating,  pea-sized  swellings,  usually  between  the 
glans  and  scrotum,  are  not  uncommon.  Strictures  which  are 
hard  and  calloused  can  readily  be  felt  along  the  course  of  the 
urethra,  but  especially  if  a  sound  is  in  situ.  Necessarily  the 
perineum  is  carefully  examined  and  one  or  both  of  Cowper's 
glands  may  show  acute  or  chronic  enlargement.  With  a 
patient  on  his  back,  and  the  legs  slightly  flexed,  a  swelling 
reaching  sometimes  as  high  as  the  navel,  occasionally  more 
on  one  side  than  on  the  other,  can  readily  be  diagnosticated 
as  a  filled  bladder  with  the  aid  of  palpation  and  percussion. 

As  regards  the  kidney,  one  should  recall  that  the  upper  two- 
thirds  are  under  the  lower  ribs,  the  i^ight  slightly  the  lower,  and 
both  adjaeent  to  the  spinal  column.  It  is  possible  to  examine 
in  different  positions.  The  most  common  is  on  the  back,  legs 
flexed,  and  patient  breathing  with  the  mouth  open.  The; 
flat  of  one  hand  is  placed  on  the  abdomen  and  finger-tips 
press  down  alongside  of  the  spleen  or  liver,  and  the  opposite 
hand  just  under  the  arch  of  the  rib  presses  upward,  both  hands 
acting  especially  at  the  time  of  expiration  in  order  to  palpate 
the  kidnev  between  the  finger-tips.  The  hallottement  of  Guyon 
is  carried  out  in  exactly  the  same  manner,  except  that  the 
hand  Avhich  is  below  gives  a  quick  snap  in  order  to  give  to 


GENITO-VBINARY  INSPECTION  AND  PALPATION.      69 

the  kidney  a  motion  which  is  to  be  recognized  by  the  finger- 
tips of  the  hand  which  is  palpating  from  in  front.  Tlie  knee- 
chest  posture  is  useful,  with  the  idea  that  the  kidney  may 
partly  take  a  position  that  will  render  it  more  readily  felt. 
Another  method  in  vogue  is  to  place  the  patient  on  the 
opposite  side  to  that  which  is  to  be  examined  ;  with  the  upper- 
most leg  drawn  upward,  and  the  thorax  brought  downward. 
In  both  instances  similar  methods  of  palpation  and  percussion 
as  the  first  method  must  be  used. 

Sometimes  it  is  necessary  to  examine  under  narcosis  in 
order  to  gain  information,  as  some  individuals  involuntarily 
resist  and  consequently  prevent  any  diagnosis  being  made. 

It  has  become  imperative,  even  in  apparently  undoubted 
cases  of  stone,  to  have  skiagraphs  taken.  The  X-ray  will 
show  the  size,  the  number,  and  their  exact  location.  Besides, 
ureteral  and  bladder-stones  are  readily  shown.  Encysted 
stones  of  the  bladder  have  been  found  in  this  manner.  The 
X-ray  may  also  disclose  other  pathological  conditions,  as 
tumors,  both  solid  and  cystic. 

Ureters  and  bladder  are  palpated  and  percussed  when 
patient  is  in  the  dorsal  position. 

Following  the  external  examination,  the  rectum  must 
always  be  explored.  Whenever  an  examination  is  undertaken 
for  the  first  time,  it  is  best,  as  patients  under  this  examina- 
tion become  faint,  to  have  them  on  their  back  or  side.  Some- 
times it  is  desirable  to  allow  them  to  stand  and  to  stoop  over 
a  table.  In  any  case  they  are  to  allow  the  perineum  to 
become  lax.  The  finger  should  be  well  oiled ;  it  is  best,  in 
order  to  protect  one's  self,  to  put  a  condom  over  the  patient's 
penis,  or  rubber  gloves  on  one's  hands.  If  no  coverings  are 
used,  the  patient  may  be  directed  to  hold  his  penis  away  from 
the  hands  of  the  examiner,  and  the  latter  should  scrape  soap 
up  and  about  his  finger-nail  in  order  to  facilitate  subsequent 
washing  off  of  fecal  matter.  In  normal  cases,  the  index-finger 
immediately  feels  the  prostate  as  a  body  the  size  of  a  chestnut, 
with  the  apex  toward  the  perineum  and  a  furrow  in  the  median 
line,  and  both  lobes  of  a  fairly  hard  consistency.  In  acute 
prostatitis    one   or   both    lobes   are    irregular  and  painfully 


70    EXAMINATION  OF  THE   URETHRA  AND  BLADDER. 

enlarged,  and  may  be  of  a  softer  consistency.  In  chronic 
prostatitis  the  gland  may  even  be  smaller  but  irregularly 
nodulated,  hard,  and  painful.  In  prostatic  abscess,  fluctuating 
areas  which  may  reach  the  size  of  an  orange  can  easily  be 
felt.  Prostatic  hypertrophy,  whenever  the  prostate  is  en- 
larged toward  the  rectun),  can  readily  be  diagnosticated. 
Tuberculous  prostatitis,  if  involvement  is  esjjecially  toward  ilie 
capsule,  can  readily  be  palpated  as  large-sized,  pin-head 
nodules.  Usually  these  cases  first  come  for  examination 
when  the  entire  parts  are  massed  together. 

The  seminal  vesicles  when  normal  can  usually,  and  when 
pathological  can  almost  always,  be  readily  felt,  especially  the 
duct  as  it  passes  through  the  prostate. 

With  the  bimanual  examination,  with  one  finger  in  the 
rectum  and  one  hand  on  the  abdomen,  ballottement  can  be 
instituted  and  the  size,  form,  surface,  and  consistency  of  the 
gland  and  bladder  made  out.  This  can  also  be  done  with  a 
sound  in  place. 

QUESTIONS  ON  EXAMINATION  BY  INSPECTION  AND  PALPATION. 

Why  is  it  advisable  to  examine  urethral  discharges  and  urine  previous  to 
any  instrumental  examination  ? 
What  may  be  seen  by  insijection  ? 
What  information  can  palpation  give  ? 
How  would  you  examine  in  order  to  palpate  the  kidney  ? 
Why  is  it  necessary  to  examine  certain  cases  under  narcosis? 
What  can  the  X-rays  show  ? 
What  is  meant  by  a  rectal  examination  ? 
What  can  be  felt'? 
What  is  a  bimanual  examination? 

INSTRUMENTAL  EXAMINATION  OF   THE  URETHRA  AND 

BLADDER. 

Previous  to  commencing  such  an  examination  all  points 
must  be  considered  as  to  whether  it  is  advisable  to  make  an 
instrumental  examination  at  the  time,  or  whether  it  has  be- 
come imperative  to  do  so  in  order  to  make  a  more  exact 
diagnosis.  There  are  a  group  of  cases  where  one  should 
abstain  from  such  an  examination.  These  are  acute  inflam- 
matory cases,  such  as  acute  urethritis,  acute  prostatitis,  abscess, 
or  acute  cystitis.     Again,  it  may  become  imperative  to  use  a 


EXAMINATION  OF  THE   URETHRA   AND  BLADDER.   71 

catheter  in  these  cases,  as  acute  retention  may  set  in  at  any 
time.  If  so,  the  anterior  urethra  should  be  thoroughly  irri- 
gated, external  orifice  cleansed,  and  a  No.  13  to  15  Charriere- 
Nelaton  catheter,  well  lubricated,  should  then  be  introduced. 
Again,  old  men,  where  there  are  symptoms  of  the  first  degree 
of  prostatic  hypertrophy,  should  not  be  subjected  too  quickly 
to  instruments,  for  many  of  these  run  a  bad  course.  If 
obligatory  to  introduce  an  instrument,  this  should  be  done 
only  under  aseptic  precautions  and  with  precision,  deliberation, 
and  gentleness. 

It  is  unnecessary  to  state  that  previous  to  an  examination 
one  should  consider  what  the  object  to  be  gained  is — in  other 
words,  it  depends  partly  on  the  history  of  the  case.  If  led 
to  believe  that  there  is  a  stricture,  the  diagnostic  sound  should 
be  the  first  instrument  to  be  introduced.  Similarly  shaped 
instruments  are  made  of  flexible  material,  then  termed  diag- 
nostic bougies.  These  are  passed  the  entire  length  of  the 
urethra,  and  infiltrations  and  narrowings  can  readily  be 
detected.  Usually  the  largest  caliber  permitted  for  introduc- 
tion at  the  external  orifice  should  be  used.  For  more  exact 
measurements  of  the  urethra  the  Otis  urethrometer  is  to  be 
recommended.  This  is  an  instrument  with  a  dilatable  part, 
which  registers  the  dilatation.  It  is  to  be  used  only  in  the 
anterior  urethra.  The  diagnostic  sound,  when  passing  into  the 
posterior  urethra,  apparently  meets  an  obstruction  and  is  even 
held  fast,  hut  this  should  not  be  mistaken  for  a  stricturous  con- 
dition. 

Some  information  can  be  obtained  with  sounds  as  regards 
the  type  of  the  stricture — whether  it  is  soft  and  acutely  in- 
flamed, or  whether  it  is  hard,  fibrous,  and  chronically  in- 
flamed— when  introducing  and  M'ithdrawing  the  instrument. 

Especially  in  the  neurotic,  apparently  a  spasm  of  the  urethra 
is  occasioned  on  the  introduction,  and  if  it  happens  to  be  a 
diagnostic  sound,  it  may  be  held  fast.  These  conditions 
should  not  be  mistaken  for  strictures,  but  are  urethral  neu- 
roses. Whenever  withdrawing  a  diagnostic  sound  or  bougie 
in  order  to  obtain  certain  information,  the  enlargement  of  the 
sound  should  be  held  fast  with  the  fingers  as  it  is  withdrawn. 


72      EXAMINATION  OF  THE   URETHRA  AND  BLADDER. 

In  doing  so,  secretions  are  expressed  from  the  urethral  glands, 
which  can  readily  be  examined  in  the  regular  manner. 

If  diagnostic  sounds  cannot  be  passed,  it  may  become 
necessary  to  use  a  metal  conical  sound.  It  is  best  to  com- 
mence with  about  a  No.  21  Charriere.  If  not  passed,  smaller 
sizes  should  be  attempted,  but  it  is  best  never  to  try  a  metal 
instrument  less  than  No.  15  Charriere,  as  urinary  infiltration 
following  false  passage  can  readily  be  caused.  Below  this 
size,  bougies  should  be  used,  and  one  or  more  filiform  bougies 
can  be  tried  at  one  and  the  same  time.  If  it  is  impossible  to 
enter  such  a  stricture  it  is  referred  to  as  an  impassable  stricture. 
So  long  as  the  patient  can  pass  urine  it  is  permeable ;  only 
when  an  acute  retention  sets  in  can  it  be  called  an  im- 
permeable stricture.  Then  if  no  instrument  can  be  passed, 
it  may  also  be  referred  to  as  an  impassable  stricture. 

In  order  to  measure  the  length  of  the  posterior  urethra, 
which  is  of  value  in  cases  of  hypertrophy  of  the  prostate,  the 
diagnostic  bougie  may  again  be  used.  When  passing  the 
bulbous  portion  beyond  the  external  sphincter,  the  length  pro- 
truding from  the  external  urethral  orifice  should  be  noted; 
then  the  sound  is  introduced  further  until  the  internal  ureth- 
ral orifice  is  passed,  and  this  can  readily  be  felt.  Now,  again, 
the  point  is  noted,  and  the  difference  shows  the  length  of 
the  posterior  urethra.  Normally,  it  is  about  4  to  4.5  cm. 
Another  method  which  is  probably  more  accurate  is  with  the 
aid  of  a  catheter.  It  is  introduced  into  the  bladder  con- 
taining fluid,  then  the  eye  of  the  catheter  withdrawn  until 
the  flow  of  fluid  from  the  catheter  stops.  The  part  extending 
from  the  external  urethral  orifice  is  noted.  Now,  a  syringe 
is  attached  to  the  catheter,  borated  water  injected,  and  the 
catheter  slowly  withdrawn.  As  soon  as  the  water  escapes 
from  the  external  urethral  orifice  along  the  side  of  the  cath- 
eter the  measurement  of  the  catheter  is  again  taken  and 
this  figure  subtracted  ;  the  difference  gives  the  length  of 
the  posterior  urethra. 

In  the  examination  of  the  bladder  it  is  necessary  to  tra- 
verse the  entire  length  of  the  urethra  with  instruments  pre- 
vious to  any  intravesical  procedure.     The  urethra  has  diiFerent 


EXAMINATION  OF  THE   URETHRA  AND  BLADDER.  73 

courses  of  direction,  varying  to  a  certain  extent  with  the  age 
of  the  individual.  The  suspensory  ligament  fixes  the  penis, 
then  necessarily  the  urethra,  and  up  to  this  point  of  fixation 
is  called  the  pendulous  urethra.  From  here  it  passes  down- 
ward, backward,  and  around  the  os  pubis.  Just  before  the 
urethra  enters  the  triangular  ligament  there  is  a  widening 
which  is  called  the  bulbous  urethra.  These  two  anatomical 
conditions  make  the  anterior  urethra.  From  the  anterior 
layer  of  the  triangular  ligament  to  its  posterior  layer  is  the 
membranous  urethra,  and  from  this  point  to  the  internal  ure- 
thral orifice  the  urethra  is  surrounded  by  prostatic  tissue ; 
hence  called  the  prostatic  urethra ;  both  parts  are  termed  the 
posterior  urethra.  The  membranous  urethra  is  surrounded 
by  the  musculus  vesicae  externus.  The  posterior  urethra  has 
a  fixed  curvature,  and  naturally  the  instruments  that  require 
the  least  force  to  pass  it  are  the  most  desirable.  The  urethra 
has  not  the  same  calibre  throughout,  but  just  within  the 
external  urethral  orifice  there  is  a  distinct  narrowing.  This 
is  called  the  fossa  navicularis,  and  on  the  upper  wall  there  is 
often  a  mucous  fold  which  forms  the  lacuna  magna,  which 
admits  instruments,  and  where  traumatism  readily  occurs. 
Variation  in  size  is  most  marked,  however,  at  the  junction  of 
the  bulbous  with  the  membranous  urethra.  There  is  appa- 
rently a  sagging  of  the  bulbous  urethra,  and  it  is  at  this 
point  that  false  passages  can  easily  be  made,  especially  when- 
ever force  is  required  to  pass  it.  For  this  reason  it  is  best 
to  keep  the  tip  of  the  instrument  in  contact  with  the  upper 
wall  of  the  urethra  at  this  point.  The  prostatic  urethra  has 
also  an  enlargement,  especially  in  old  age,  and  in  some  cases 
the  course  of  the  urethra  changes  entirely,  due  to  the  variable 
shapes  which  a  prostatic  growth  may  take.  It  is  on  account 
of  the  distortion  of  the  urethra  in  these  cases  that  we  explain 
the  difficulty  of  passing  instruments.  However,  inflexible 
instruments  which  are  to  be  used  in  the  posterior  or  deep 
urethra  should  be  made  with  a  curve  which  corresponds  with 
the  fixed  curve  at  this  part  of  the  urethra. 

Instruments  are   made  of  non-flexible   material,  such    as 
metal,  and  retain   their  shape ;  or  of  soft,  elastic,  or  semi- 


74     EXAMINATION  OF  THE   URETHRA  AND  BLADDER. 


f 


Fig.  1.— From  left  to  right 
in  series  are  the  blunt- 
pointed,  soft-rubber  cath- 
eter, the  double-end  diag- 
nostic sound  (bougie  -  a- 
boule),  and  the  single  Coud6 
catheter  (elbow  catheterj. 


elastic  material,  which  do  not  retain 
their  exact  shape.  Instruments  are  of 
metal,  then  called  sounds  ;  or  of  elastic 
material,  then  called  bougies.  Both  are 
used  for  the  purpose  of  dilatation  of  the 
urethral  canal.  No  matter  of  what  ma- 
terial they  may  be  made,  instruments 
which  have  a  channel  through  their 
length  are  called  catheters.  These  are 
used  either  to  withdraw  fluid  or  inject 
it  into  the  bladder.  If  made  of  soft 
rubber,  termed  Nelaton ;  if  of  woven 
silk,  covered  with  shellac,  and  flexible 
at  ordinary  temperature,  called  French ; 
if  not  flexible  at  ordinary  room-temper- 
ature, but  flexible  in  warm  water,  they 
are  called  English  catheters.  Shape  is 
given  to  these  latter  by  placing  them  in 
warm  water  and  giving  the  metal  man- 
drin  the  desired  shape.  On  cooling, 
they  retain  the  shape  given  to  them. 
Metal  instruments  are  best  kept  ster- 
ile by  boiling  in  water  or  sterilizing  like 
any  other  metal  instruments.  The  Ne- 
laton  catheters  may  be  boiled,  but  be- 
come brittle  after  treating  them  in  this 
manner.  French  and  English  instru- 
ments, as  well  as  all  other  instruments, 
should  be  washed  with  cold  water  so 
that  in  case  albuminous  matter  clings 
to  them,  it  does  not  become  coagulated. 
Then  place  in  1  :  2000  bichloride  of 
mercury  solution.  This  is  always  to 
be  loashed  off  vnth  cold  sterile  water. 
Again,  formalin  vapors  can  be  used 
for  sterilizing  instruments.  They  must 
remain  in  contact  for  some  time,  and 
here    again    thoroughly   washed   before 


EXAMINATION  OF  THE   URETHRA   AND  BLADDER.   75 

using,  as  formalin  is  irritating  to  the  urethra.  The  subject  of 
sterilization  of  these  particular  instruments  still  requires  much 
consideration. 

As  regards  lubricants,  5  per  cent,  boric  acid  in  glycerin  or 
olive  oil,  which  must  be  sterile,  are  acceptable,  although 
numerous  preparations  are  made  for  this  purpose. 

French  catheters  having  a  tip  which  is  set  at  more  or  less 
of  an  acute  angle  are  called  Mercier  or  Coude.  Occasionally 
the  tip  has  a  double  curvature,  and  is  then  referred  to  as  a 
bicoude  catheter.  These  instruments  are  to  be  recommended 
in  cases  of  prostatic  enlargement,  as  their  tips  readily  pass 
into  the  posterior  urethra.  The  bougie-a-boule  (ball-sound), 
or  diagnostic  bougie,  is  made  from  similar  material. 

The  Mercier  or  prostatic  catheters  are  used  wherever  an 
enlarged  prostate  is  suspected,  or  whenever  a  soft-rubber 
catheter  cannot  be  passed.  There  are  French  catheters  which 
have  conical,  cylindrical,  olive-pointed  tips,  and  each  can  be 
used  to  advantage  in  diiferent  cases,  selection  of  which  depends 
on  experience  almost  entirely. 

Retention  of  urine  is  of  great  importance.  It  is  the 
amount  of  urine  which  remains  in  the  bladder  after  a  volun- 
tary urination  and  is  of  significance  in  certain  cases. 

In  acute  retention  of  urine,  when  due  to  acute  inflammatory 
troubles,  the  smallest  caliber  N^la ton  catheter  should  be  used. 
Not  so  in  cases  of  retention  in  the  course  of  a  prostatic 
hypertrophy.  Here  at  least  a  large  size,  if  possible  a  28- 
Charriere,  should  at  once  be  used.  English  catheters  are 
scarcely  ever  used,  although  there  may  be  certain  cases  in 
which  they  may  be  desirable. 

As  regards  metal  instruments,  they  may  have  a  two-fold 
use — either  to  act  therapeutically  on  the  walls  of  the  urethra 
or  for  diagnostic  purposes  within  the  bladder.  For  the  for- 
mer, instruments  should  be  so  shaped  that  the  urethra  may 
retain  its  natural  curvature  when  they  are  in  the  canal.  When 
used  for  the  second  purpose,  it  suffices  if  they  are  able  to  pass. 

Sounds  used  for  narrow  strictures  should  be  conical,  so  that 
the  tip  may  readily  enter  a  stricture  ;  if  used  where  but  local- 
ized areas  of  inflammation  exist,  the  sounds  may  be  cylindrical. 


76    CATHETERIZATION  OR  SOUNDING  OF  THE  URETHRA. 

■CATHETERIZATION  OR  SOUNDING  OF  THE  URETHRA. 

Too  often  rough  handling  and  inabihty  to  pass  instruments 
have  caused  much  pain  and  ill  results  to  patients.  For  this, 
if  for  no  other,  reason  it  is  well  for  a  student  to  give  attention 
to  this  subject.  To  carry  out  the  procedure  in  detail,  the  hands 
of  the  surgeon,  the  instrument,  and  the  field  of  work  should 
be  sterile.  The  patient  is  best  placed  on  his  back,  with  the 
hips  slightly  elevated,  and  the  external  urethral  orifice  well 
cleaned  with  antiseptic  fluid.  The  ordinary  method  for  pass- 
ing instruments  is  known  as  tour  du  ventre.  With  the  little 
finger  of  the  hand  holding  the  sound  or  metal  catheter  rest- 
ing on  the  abdomen,  and  parallel  to  it  in  the  median  line, 
the  tip  of  the  instrument  enters  the  external  urethral  orifice, 
which  is  held  apart  with  the  fingers  of  the  other  hand,  thus 
making  the  beginning  step.  The  glans  is  then  j)uUed  up  and 
over  the  sound,  while  the  hand  on  the  abdomen  still  retains  the 
original  position.  When  the  penis  cannot  he  brought  up  any 
further,  the  tip  of  the  instrument  is  gradually  lowered  and  the 
handle  raised  until  the  instrument  reaches  the  vertical  position. 
In  doing  this  the  tip  should  follow  the  npper  wall  of  the 
urethra.  If  not,  the  tip  reaches  the  bulging  bulbous  urethra, 
usually  at  its  base.  For  this  reason  the  finger-tips,  those  of 
the  index  and  middle  and  of  the  thumb,  apparently  grasp  or 
direct  it  at  the  perineum,  but  are  not  to  be  used  as  the  ful- 
crum of  a  lever.  Thus  the  tip  enters  the  membranous  urethra 
by  being  directed  upward,  so  that  it  may  take  the  correct 
course.  Occasionally  it  may  be  desirable  to  introduce  the 
index-finger  into  the  rectum,  and  with  the  aid  of  the  thumb 
on  the  perineum  guide  the  tip  of  the  sound.  The  usual  error 
is  either  to  raise  the  tip  of  the  instrument  before  the  mem- 
branous urethra  is  reached,  and,  if  boring  motion  is  used, 
false  passages  in  the  upper  wall  of  the  bulbous  urethra  are 
easily  made  ;  or  the  tip  of  the  instrument  is  allowed  to  reach 
the  lowest  portion  of  the  bulbous  urethra,  into  which  the 
membranous  urethra  partly  overhangs ;  hence  if  force  be  used, 
the  instrument  passes  through  this  tissue,  which  readily  allows 
of  urinary  infiltration.     Even  after  passing  through  this  diffi- 


CATHETERIZATION  OB  SOUNDING  OF  THE  URETHRA.    77 

cult  space  the  instrument  may  still  meet  with  obstruction  in 
tlie  prostatic  urethra.  If  clue  to  enlargement,  and  if  the  pas- 
sage has  become  tortuous,  great  care  should  be  taken  not  to 
pass  the  tip  through  the  prostatic  urethra.  The  tip  may  be 
caught  where  the  sinus  pocularis  is  patent,  and  a  false  passage 
readily  established  between  it  and  the  bladder,  entering  tlie 
same  below  the  external  orifice. 

There  are  other  modes  of  introduction  of  instruments,  but 
practically  all  are  modifications  of  the  preceding  method. 
}Mierever  no  severe  pathological  conditions  exist,  the  iceight  of 
the  sound,  if  rightly  directed,  passes  the  instrument  correctly.  In 
li-ithdr awing  an  instrument  the  exact  reverse  motions  are  pursued. 
When  the  beak  of  the  sound  is  in  the  bladder,  it  should  be 
movable  from  side  to  side,  and  also  from  above  downward, 
and  vice  versa.  If  it  happens  to  be  a  catheter,  the  urine  in 
the  bladder  passes  from  it. 

Instruments  which  are  used  for  diagnostic  purposes  within 
the  bladder  must  be  of  such  a  shape  that  every  part  of  the 
wall  of  the  bladder  can  be  reached  with  it.  Thompson  has 
shown  that  the  beak  should  be  almost  at  right  angles  to  the 
shaft,  and  scarcely  more  than  2  cm.  in  length.  The  handle 
should  be  cylindrical  and  hollow,  so  that  the  sound  of  striking 
a  calculus,  for  example,  carried  by  the  shaft,  may  be  magni- 
fied. A  modification  of  this  instrument  is  that  it  is  a  cath- 
eter at  the  same  time.  In  certain  cases  it  is  desirable  to  in- 
troduce or  withdraw  fluid,  so  that  an  examination  may  be 
more  thoroughly  carried  out.  Whenever  such  an  instrument 
is  inserted  immediately  after  urination,  and  if  urine  remains 
in  the  bladder,  it  may  be  withdrawn  and  the  quantity  meas- 
ured, which  is  called  the  residual  or  retention  urine.  If  the 
urine  is  expelled  so  that  it  passes  in  a  perfect  stream  from 
the  catheter  opening,  it  signifies  the  contractile  power  of  the 
bladder-wall.  If  it  falls  abruptly  from  the  catheter  opening, 
it  shows  an  atonic  condition  of  the  bladder-wall. 

After  the  introduction  of  an  instrument  into  a  normal 
bladder,  if  the  beak  is  turned  downward,  and  then  a  stroking 
motion  given  to  the  beak  both  backward  and  forward  and 
from  side  to  side,  the  velvety  sense  of  touch  of  the   normal 


78    CATHETERIZATION  OB  SOUNDING  OF  THE  URETHRA. 

mucosa  is  imparted.  But  a  short  distance  back  of  the  in- 
ternal urethral  orifice,  and  on  both  sides  of  the  median  line, 
an  elevation  is  met  with  wliich  corresponds  to  the  interureteral 
ligament.  Within  this  triangular  region,  called  the  trigonum, 
there  is  apparently  a  tenseness  of  the  bladder  compared  to 
the  rest  of  the  bladder-wall. 

This  method  of  examination  with  such  a  sound,  termed 
done  sound,  has  not  the  value  that  it  was  formerly  supposed 
to  possess,  on  account  of  other  methods  of  examination.  It 
should  not  be  carelessly  used,  as  pathological  conditions 
become  worse  by  interference  with  hard  instruments ;  if 
hemorrhages  or  ulcers  exist,  these  can  become  aggravated. 
Hard,  infiltrating  masses  can  be  distinguished,  but  not  poly- 
poid tumors,  unless  of  enormous  size.  It  is  adapted  for 
finding  stones  in  the  bladder.  If  not  encysted  in  the  bladder- 
wall,  the  stone  is  in  the  most  dependent  portion  of  the  blad- 
der cavity,  and  can  in  most  cases  be  readily  felt,  and  a  "  click  " 
is  given  to  the  instrument,  which  is  characteristic  of  such  a 
condition,  varying  in  intensity  with  the  size  and  character 
of  the  stone.  Trabecule  can  readily  be  made  out ;  besides, 
an  idea  can  be  obtained  of  the  size,  number,  and  contour  of 
the  lobes  of  the  prostate  when  protruding  into  the  bladder 
cavum. 

QUESTIONS  ON  THE  INSTEUMENTAL  EXAMINATION  OF  THE 
URETHRA  AND  THE  BLADDER. 

In  what  class  of  cases  is  it  necessary  to  make  instrumental  examinations? 

Would  you  do  so  in  an  acute  inflammatory  disease  ?     Why  not? 

How  would  you  proceed  in  cases  where  you  suspect  a  stricture?  In  hyper- 
trophy of  the  prostate  ? 

What  ic  meant  by  a  spasmodic  stricture? 

How  would  you  diagnose  an  organic  stricture  ? 

How  would  you  measure  its  calibre? 

How  would  you  measure  the  length  of  the  posterior  urethra? 

What  are  the  anatomical  divisions  of  the  urethra  ?  What  are  the  clinical 
divisions? 

Has  the  posterior  urethra  a  fixed  curvature  ? 

What  are  the  enlargements  of  the  urethra? 

Of  what  importance  are  they  especially  when  passing  instruments? 

Of  what  material  are  instruments  made  ? 

What  are  sounds?     bougies?     catheters? 

W[^a.t  is  a  Nelaton  catheter?     French  catheter?     English  catheter? 

For  practical  purposes  how  would  you  sterilize  this  class  of  instrument? 


URETHROSCOPY.  79 

What  are  lubricants?  Meution  those  that  are  satisfactory  for  genito- 
uriuary  surgery. 

What  is  a  Mercier  or  Coude  catheter ?     bicoude  catheter? 

What  is  the  special  use  of  these  Coude  catheters  ? 

In  what  class  of  cases  are  these  of  special  value  ? 

What  is  reteution  of  urine? 

In  acute  retention  of  urine  during  the  course  of  an  acute  inflammatory 
disease,  what  kind  of  catheter  should  be  used  to  withdraw  the  urine  ?     Why  ? 

In  retention  due  to  prostatic  hypertrophy,  what  kind  of  a  catheter  should 
be  used? 

For  what  purposes  are  solid  metal  insti'uments  ? 

Describe  difl:erently  shaped  sounds. 

What  is  meant  by  catheterization  or  sounding  ? 

Do  bad  results  ever  follow  rough  handling  of  the  urethra  ?     Describe  such. 

In  what  position  should  the  patient  be  placed  for  catheterization  ? 

What  is  meant  by  the  tour  da  ventre  f 

Describe  in  detail  the  passing  of  a  sound,  naming  its  cautions. 

Is  the  finger  ever  introduced  into  the  rectum  when  sounding  ?     If  so,  why  ? 

What  is  a  false  passage  ? 

Can  these  easily  occur?     Where  do  they  occur  most  often?     Why  ? 

How  can  you  state  whether  or  not  the  beak  of  the  instrument  is  in  the 
bladder? 

Instruments  used  for  diagnostic  purposes  within  the  bladder  have  what 
shape,  and  why  ? 

How  can  you  state  whether  or  not  a  catheter  is  in  the  bladder  viscus? 

What  is  meant  by  a  Thompson  stone  sound,  or  searcher? 

What  is  the  advantage  in  having  this  instrument  as  a  catheter  at  the  same 
time? 

What  may  be  felt  with  such  an  instrument  in  the  normal  bladder? 

Has  it  as  much  value  as  formerly  ?     Why  not  ? 

In  what  class  of  cases  should  it  not  be  used?     Why  not? 

How  do  you  recognize  a  stone  with  this  instrument  ? 

URETHROSCOPY. 

By  this  term  is  meant  the  examination  of  the  urethra  by 
the  aid  of  sight.  For  all  practical  purposes  two  distinct  types 
of  instrument  are  recognized  and  both  have  their  uses.  Both 
consist  of  tubes  varying  in  length  and  diameter. 

1.  When  the  source  of  light  is  outside  of  the  tube,  which 
is  introduced  into  the  urethra,  and  where  it  is  reflected  to  the 
point  of  examination.  Casper  and  Otis  instruments  are  ex- 
amples of  this  variety. 

2.  Where  the  source  of  light  is  introduced  with  the  tube, 
and  the  light  is  at  the  point  of  examination,  it  is  called  the 
direct  method.  Examples  are  the  Nitze,  Oberlander,  Koch, 
and  Guiteras  instruments. 

No  matter  which  instrument  is  used,  certain  accessories  are 


80 


URETHROSCOPY. 


Fig.  2. 


The  Koch  urethroscope. 


necessary  for  iutra-iirethral  work 
— e.  g.,  cotton  carriers,  canula  to 
connect  with  a  syringe,  small 
knife,  electrodes,  etc. 

The  technique  for  an  examina- 
tion is  as  follows  :  The  patient 
may  be  either  in  a  sitting  posi- 
tion or  in  a  lithotomy  position. 
For  all  ordinary  work  he  may  be 
on  an  examining  table,  on  his 
back,  with  hips  considerably  ele- 
vated, and  the  legs  spread  apart. 
After  using  ordinary  antiseptic 
precautions  the  instrument  with 
maudrin  is  introduced.  If  it  is 
desired  to  insert  it  into  the  pos- 
terior urethra,  the  suspensory 
ligament  is  made  lax  by  placing 
the  left  hand  on  the  pubic  re- 
gion and  making  it  give,  so  that 
the  instrument  held  with  the 
right  hand  passes  almost  without 
effort  into  and  through  the  pos- 
terior urethra. 

There  are  but  rare  instances 
where  any  local  ansesthetics  are 
required.  If  so,  with  a  Guyon 
capillary  catheter,  1  to  2  c.c.  of 
a  3  per  cent,  eucain  or  cocaine 
solution  are  sufficient  to  anaes- 
thetize the  ])arts.  All  local  ances- 
thefics  change  the  appearance  of 
the  urethra,  hence  it  is  best  to 
avoid  their  use.  It  is  best  to  in- 
sert the  largest  tube  that  will 
enter  the  external  urethral  orifice. 


URETHROSCOPY.  81 

Normal  Features. 

There  are  distinct  normal  findings.  In  order  to  understand 
what  is  seen  in  a  nrethroscopic  examination  these  must  be 
fully  understood.  The  central  figure  varies  with  the  part  of 
the  urethra  :  so  much  so  that  the  part  can  be  recognized  from 
it  alone.  Besides,  the  radiating  lines,  gloss,  and  color  all 
vary  in  individual  cases.  Commencing  with  the  internal 
urethral  orifice  and  gradually  withdrawing,  the  first  most  im- 
portant structure  to  be  noticed  is  the  colliculus  seminalis. 
Above  this,  the  opening  of  the  ductus  ejaculatorii,  and  along- 
side, the  ductus  prostatici.  The  sinus  pocularis  can  be  recog- 
nized as  a  slit  on  the  uppermost  part.  Withdrawing  still 
further,  the  commencement  of  the  cajnit  gallinaginis  is  seen. 
This  gives  a  somewhat  crescent-shaped  protuberance.  Still 
further  along  the  j)<^^'^  memhranacea  is  reached.  Here  the 
central  figure  is  of  a  vertical,  slit-like  appearance,  with  the 
lower  and  upper  parts  with  many  radiations.  The  p><^'^"''s  bul- 
bosa  shows  the  openings  of  the  ducts  of  Goicpei^s  glands. 
Pars  cavei^nosa  shows  the  central  figure  as  a  slightly  horizon- 
tal slit.  In  this  portion  MorgagnV s  crypts  and  the  openings 
of  the  glands  of  Littre  are  to  be  seen.  Finally,  the  fossa 
navieularis  is  reached,  showing  a  triangular  central  figure. 

PATHOLOGICAL  FEATURES. 

It  will  be  impossible  to  mention  in  detail  the  pathological 
findings,  yet  it  will  be  necessary  to  enumerate  them. 

They  consist  principally  of  the  epithelial  lining,  which  nor- 
mally shows  a  smooth  and  equally  glossy  appearance.  In 
diseased  areas  the  gloss  may  be  absent  or  be  diminished  and 
occur  in  patches,  or  it  may  be  granular  in  appearance  and 
more  or  less  diffusely  the  color  may  not  be  the  normal  rose-tint, 
and  the  striations  and  reflex  irregular.  The  glands  and  crypts 
are  commonly  affected,  and  their  openings  may  show  a  swollen 
condition.  In  subacute  and  chronic  urethral  inflammations, 
OberlJinder  distinguishes  soft  from  hard  infiltrations.  The 
posterior  urethra  shows  many  variations,  as  the  caput  galli- 
6— V.  D, 


82  CYSTOSCOPY. 

uaginis  is  often  affected.  Besides  these  changes,  tuberculosis, 
tumors,  such  as  polyps,  traumatism,  and  openings  of  strictures 
may  readily  be  recognized. 

All  these  conditions  may,  of  course,  be  treated  intra-ure- 
thrally  with  electrolysis,  and  all  other  applications,  etc.,  made 
directly  under  the  supervision  of  the  eye. 

CYSTOSCOPY. 

Cystoscopy  is  the  method  by  which  the  inner  surface  of  the 
bladder  is  examined  by  inspection. 

In  cases  of  women,  Simon  dilated  the  urethra  with  sounds 
of  gradually  increasing  size,  and  the  inner  surface  of  the 
bladder  was  palpated.  Kelly  uses  tubes  with  mandrins,  the 
tubes  not  so  large  in  diameter  as  the  sounds  of  Simon.  If 
patients  are  put  in  the  knee-chest  position,  after  the  removal 
of  the  mandrin  the  bladder  fills  with  air.  Then,  either  with 
a  head-mirror  or  a  small  electric  light  which  may  be  intro- 
duced along  the  side  of  the  inner  wall  of  the  tube,  the  blad- 
der surfaces  may  be  examined ;  besides,  smaller  intravesical 
operative  procedures  can  be  undertaken.  The  Kelly  method 
can  also  be  used  in  the  male,  but  not  with  so  much  satisfaction. 

The  Nitze  cystoscope  is  the  prototype  of  all  the  instruments 
used  at  the  present  time.  It  consists  of  a  metal  tube  with  a 
bend  like  a  Mercier  catheter.  In  the  beak  is  a  small  Edison 
incandescent  lamp  with  the  open  surface  facing  upward.  At 
the  ocular  end  of  the  funnel-shaped  tubing  the  electric  insula- 
tion attachment  is  fastened.  Just  at  the  concavity  of  the 
beak  and  shaft  there  is  a  square  opening  set  with  a  prism. 
Now,  with  the  small  telescope  which  is  fitted  in  the  tube, 
everything  that  is  seen  by  looking  through  the  ocular  is  at 
right  angles  to  the  axis  of  the  instrument,  as  thepj-ism  refracts 
at  this  angle. 

Nitze  also  introduced  instruments  whereby  no  prism  was 
used,  but  where  the  objects  seen  were  directly,  and  again  where 
tlie  prism  was  so  set  that  the  angle  of  refraction  was  greater 
than  90  degrees. 

The  Preston  cystoscope  is  so  made  that  it  can  be  used  with 


CYSTOSCOPY. 


83 


or  without  its  optical  part.     When  with  it,  the  principle  is 

exactly  like  the  Nitze  cystoscope.     When  without,  the  view 

is  uninterrupted  ;  in   other  words,  is  direct. 

As  the  lamps  used  give  off  but  little  heat,  Fig.  3. 

these  cystoscopes  can  be  used  in  a  bladder 

dilated  with  air.     All  European  instruments 

are  now  provided  also  with  cold  lamps,  yet 

water  is  used  for  dilatation  of  the  bladder, 

as  tumors  or  membranes  float  readily  in  the 

same,  allowing  correct  judgment  as   to   the 

character  of  such  pathological  findings. 

Modifications  of  these  instruments  have 
been  made  so  that  they  may  be  used  for 
catheterization  of  the  ureters — then  called 
catheterization  cystoscopes.  The  Kolischer  op- 
eration cystoscope  is  one  which  permits  a  direct 
view,  and  underneath  the  tubing  for  the  opti- 
cal part  there  is  a  small  canal  which  permits 
the  introduction  of  curettes,  scissors,  etc.,  and 
allows  intravesical  operations  under  the  direct 
view  of  the  eye.  The  Nitze  operation  cysto- 
scope is  a  much  more  complicated  instrument. 

In  order  to  perform  cystoscopy  successfully  Nitze's  cystoscope. 
certain  requirements  are  necessary  : 

1.  The  urethra  must  be  sufficiently  large  to  admit  the  in- 
strument, and  free  of  narrow  strictures,  etc. 

2.  The  bladder  must  be  dilatable  to  at  least  75  to  150  c.c. 
whenever  cystoscopes  are  used  which  require  dilatation  with 
water ;  when  with  air,  the  bladder  need  not  be  dilated. 

3.  The  fluid  used  for  filling  the  bladder  must  be  clear.  If 
bloody  or  turbid  from  pus,  an  examination  cannot  be  carried 
out. 

To  lubricate  urethroscopes  and  cystoscopes  it  is  best  to  use 
a  substance  that  is  miscible  with  water :  sterilized  glycerine 
is  satisfactory. 

Occasionally,  local  ansesthesia  is  necessary  to  carry  out  an 
examination.  It  is  best,  some  fifteen  minutes  before  an  exami- 
nation, to  insert  into  the  rectum  a  0.01  gramme  morphine  sup- 


84  CYSTOSCOPY. 

pository.  In  addition  to  this,  5  to  15  c.c.  of  a  2  to  5  per 
cent,  solution  of  eucain  or  cocaine,  as  the  ease  demands,  should 
be  distributed  along  the  empty  bladder  and  entire  urethra. 
Before  using  cocaine  the  patienth  idiosyncrasy  against  it  must 
be  established.  Besides,  25  to  50  c.c.  of  a  5  per  cent,  solu- 
tion of  antipyrin  solution  can  be  injected  directly  into  the 
bladder  ten  minutes  j3reyious  to  an  examination. 

With  the  aid  of  cystoscopy,  the  diagnosis  of  bladder  and 
renal  diseases  has  made  enormous  strides.  It  is  regrettable 
that  the  instrument  has  not  become  more  general  in  its  use. 
The  entire  bladder  surface  can  be  thoroughly  examined ;  the 
trigonum  and  the  parts  about  the  internal  urethral  orifice 
demand  most  attention.  Hypertrophy  of  the  prostatic  lobes, 
disease  of  the  trigonum,  cystitis,  ulcerations,  rhagades,  etc.,  can 
all  readily  be  diagnosticated.  Even  if  the  ureters  are  not 
catheterized,  the  urine  often  can  readily  be  seen  as  it  spurts 
from  the  ureteral  orifices ;  if  bloody  or  purulent,  it  can  be 
recognized.  With  the  operative  cystoscopes  small  tumors 
may  be  removed,  stones  crushed,  and  ulcerations  curetted  and 
cauterized. 

Previous  to  the  discovery  of  cystoscopy  and  radiography 
many  exploratory  operations,  especially  perineal,  were  per- 
formed in  the  male.  These  have  now  become  obsolete.  Oper- 
ations on  the  kidney  are  now  also  made  with  more  certainty, 
since  urine  from  both  kidneys  has  been  collected,  since  both 
ureters  have  been  sounded  or  catheterized,  and  since  skiag- 
raphy and  cystoscopy  have  come  into  general  use ;  in  other 
words,  differential  diagnosis  of  kidney,  ureteral,  bladder,  and 
posterior  urethral  diseases  can  be  made  with  comparative  ease 
with  the  modern  instruments  at  our  command. 

QUESTIOXS  ON  UEETHEOSCOPY  AND  CYSTOSCOPY. 

What  is  urethroscopy  ? 

V^Tiat  is  a  urethroscope,  and  what  two  types  are  in  common  use? 

What  is  the  technique  for  urethroscopy  ? 

Would  you  use  a  local  ansesthetic  ? 

What  are  the  objections  to  the  use  of  cocaine? 

Describe  the  normal  findings  of  urethroscopy. 

Of  -what  do  the  pathological  conditions  principally  consist? 

In  the  treatment  of  urethral  disease,  has  this  method  any  advantages  ? 


CASE-HISTORIES  AND  RECORDS.  85 

What  is  cystoscopy  ? 

Describe  the  Kelly  niethed  of  examining  the  bladder.  Can  it  be  used  in 
the  male  ? 

What  is  a  cystoscope? 

Describe  the  plain  Nitze  cystoscope. 

What  is  meant  by  a  catheterization  cystoscope  ? 

What  is  meant  by  an  operation  cystoscope  ? 

What  are  the  requirements  for  cystoscopy  ? 

If  necessary,  how  would  you  anaesthetize  the  parts  ? 

Why  is  it  necessary  to  know  the  idiosyncrasy  for  cocaine  ? 

With  what  would  you  lubricate  the  instruments? 

In  the  treatment  of  intravesical  disease,  how  are  these  instruments  used  ? 

In  the  diflferential  diagnosis  of  bladder  and  kidney  disease,  how  are  they 
of  use? 

Case -Histories  and  Records. 

Every  instrumental  examination  involving  the  urinary 
tract  should  be  preceded  by  a  careful  history  of  the  case.  It 
is  almost  needless  to  state  that  the  most  important  part  of 
the  anamnesis  in  a  case  suifering  from  a  genito-urinary  dis- 
ease is  that  which  is  directly  referable  to  the  organs  affected. 
Whether  or  not  and  when  any  gonorrhoeal  infections  occurred, 
their  number,  their  course,  and  their  duration,  whether  com- 
plicated in  any  manner  with  swollen  testicles,  chills,  or  other- 
wise, must  be  known.  The  mode  of  treatment,  whether  or 
not  with  instruments,  should  be  asked.  Then,  again,  especial 
attention  should  be  giveu  to  the  present  complaint.  When 
first  noticed,  whether  or  not  a  cause  is  suspected,  and  its  entire 
course  should  be  elicited  with  reference  to — 

1.  Frequency  of  urination. 

2.  Whether  or  not  pain  is  present. 

3.  Quantity  and  character  of  the  urine. 

4.  What  kind  of  stream. 

5.  Whether  or  not  a  discharge  from  the  urethra  is  present. 
Now,  in  order  to  facilitate  matters,  a  few  questions  may  be 

enumerated  which   give  important  information  in  a  concise 
form  : 

1 .  How  often  do  you  urinate — during  the  day  ?  during 
the  night? 

2.  Have  you  pains?  When — before  urination?  during 
urination  ?  after  urination  ?  or  in  the  interval  between  urina- 
tions?    Where  is  the  pain? 


86  MALFORMATIONS,  INJURIES,   OF  PENIS. 

3.  How  much  urine  do  you  pass — small  quantity  ?  large 
quantity  ? 

4.  What  kind  of  stream — Force?  Size?  Form?  Direc- 
tion? 

5.  Is  there  a  discharge — before  urination?  after  urina- 
tion ?     Is  it  non-purulent  ?     Purulent  ?     Bloody  ? 

After  this  preliminary  questioning  and  examinations  of 
discharge  and  urine,  the  physical  examination  is  proceeded 
with.  To  enumerate  rapidly :  Inspection,  palpation,  then 
rectal  examination.  The  instrumental  examination  varies  as 
to  the  history  of  the  case.  If  stricture  is  suspected,  diagnostic 
bougies  or  sounds,  and  then  the  urethroscope ;  if  stone,  then 
stone  sound  or  cystoscope  ;  if  an  acute  urethral  discharge  is 
present,  it  is  probably  advisable  to  omit  any  instrumentation 
of  the  urethra  on  account  of  the  possibility  of  causing  compli- 
cations. No  exact  outline  can  be  given  for  all  cases,  as  it  may 
vary  with  each  instance. 

QUESTIONS. 

Why  should  a  history  precede  every  instrumental  examination?    • 

On  which  part  of  the  history  should  stress  be  laid  ? 

In  the  affection  under  consideration,  why  should  special  attention  be  paid 
to  number  of  times  of  urination,  pain,  urine,  stream,  and  discharge  ? 

Previous  to  the  physical  examination,  should  the  urine  be  examined? 
Why? 

How  would  you  proceed  to  examine  a  patient  with  a  genito-urinary  dis- 
ease ? 

Is  it  advisable  to  examine  a  patient  with  an  acute  discharge  ?    If  not,  why  ? 

Is  there  any  definite  rule  to  take  in  the  instrumental  examination  of  pa- 
tients? 

CONGENITAL  MALFORMATIONS,  INJURIES,  AND 
DISEASES  OF  THE  PENIS. 

MALFORMATIONS  OF  THE  PENIS. 

Cases  are  recorded  of  complete  absence  and  rudimentary 
formation  of  the  penis ;  also  double  penes,  and  in  these  cases 
usually  double  urethras  and  bladders. 

INJURIES  OF  THE  PENIS. 

The  subcutaneous  tearing  of  the  corpora  cavernosa  rarely 
occurs  at  any  other  time  except  during  an  erection,  and  is 


DISEASES   OF  THE  PENIS  87 

referred  to  as  fracture  of  the  penis.  It  may  occur  in  any 
portion  of  the  corpora  cavernosa.  Usually  there  is  the  for- 
mation of  a  hsematoma,  the  absorption  of  which  requires 
considerable  time,  but  contractures  of  the  penis  at  the  time 
of  erection  often  remain.  It  may  require  permanent  cathe- 
terization and  moist  antiseptic  applications  to  prevent  urinary 
infiltration.  All  injuries,  whether  of  crushing  character, 
stabs,  or  otherwise,  indicate  the  regular  surgical  treatment. 

DISEASES  OF  THE  PENIS. 
Balanitis  and  Posthitis. 

Balanitis  is  a  superficial  inflammation  of  the  glans  penis. 
Posthitis  is  an  inflammation  of  the  inner  leaf  of  the  prepuce. 

If  these  two  disorders  accompany  each  other,  which  is  the 
rule,  it  is  then  termed  balano-posthitis.  The  non-venereal 
balano-posthitic  aifections  are  commonly  caused  by  the  retention 
and  decomposition  of  the  smegma  in  unclean  patients.  This 
decomposition  produces  fatty  acids,  which  erode  the  epidermis. 
Prolonged  contact  with  gonorrhoeal  discharge  may  produce  the 
same  result.  Therefore  it  may  be  either  venereal  or  non- 
venereal.  As  a  result,  redness  and  moisture  or  superficial 
erosions  may  appear,  which  discharge  pus  quite  freely.  A 
predisposition  for  this  trouble  is  established  if  the  prepuce  is 
very  long  and  its  opening  very  small.  When  this  occurs  in 
men  of  middle  age,  there  is  more  or  less  chronic  balano-pos- 
thitis. Once  in  a  while  the  glands  in  the  inguinal  region 
become  infected  and  enlarged,  but  suppuration  in  them  is  a 
rather  rare  occurrence.  The  first  principle  of  the  therapy  is 
cleanliness.  Quite  often  a  few  warm-water  injections  suffice 
to  reduce  the  inflammation.  In  severe,  non-venereal  cases 
we  introduce,  between  glans  and  prepuce,  a  piece  of  cotton 
or  absorbent  gauze  which  is  soaked  in  an  astringent  and 
mildly  antiseptic  solution  of  the  following  formulse  : 

^     Aluminis  crudis,  1.0  gramme; 

Liq.  plumbi  acetat.  fort.,    5.0  grammes  ; 

Aquffi  destillatae,  300.0         " 

M.  &  Sig. — External  use  as  directed. 


88  DISEASES  OF  THE  PENIS. 

^i     Zinci  sulphocarbolatis,      0.25  gramme  ; 

Acidi  borici,  2.50  grammes ; 

Aquse  destillate,  100.00       " 

M.  &  Sig. — External  use  as  directed. 

Or  cleanse  parts  with  warm  water  and  then  with  peroxide 
of  hydrogen ;  dry  and  dust  with  dermatol. 

This  latter  treatment  will  answer  for  those  cases  caused  by 
the  gonococcus.  In  all  chronic  cases  circumcision  should  be 
resorted  to,  and  as  a  prophylactic  measure  against  other  attacks 
after  an  acute  case  has  subsided. 

Inert  dusting-powder  or  astringent  antiseptic  powders,  such 
as  the  following,  can  be  used  frequently  daily  after  first 
cleansing  the  parts : 

^6     Pulv.  zinci  oxidi, 

Pulv.  talci,  aa  5.0  grammes. 

M.  &  Sig. — Dust  on  the  parts  as  necessary. 
Or— 

I^     Acidi  borici,  5.0  grammes ; 

Acidi  salicylici,  1.0  gramme; 

Hydrarg.  chlor.  mit.,        2.5  grammes. 
M.  &  Sig. — Apply  locally  as  needed. 

Herpes  Progenitalis. 

Herpetic  vesicles  are  common  and  most  often  multiple, 
arranged  in  groups  on  a  more  or  less  slightly  reddened  base, 
appearing  on  the  mucous  membrane  and  also  on  the  skin  of 
the  penis.  If  arising  on  the  skin,  they  dry  quickly  and  form  a 
scab,  but  when  on  the  mucous  membrane,  the  vesicles  break 
open  and  ulceration  sets  in.  When  but  one  vesicle  occurs,  it 
may  be  round,  but  usually  confluent  and  irregularly  shaped 
erosions  occur.  In  diagnosing,  the  cause  should  be  considered, 
and  it  must  be  remembered  that  they  may  lead  to  a  balano- 
posthitis  and  occasionally  to  a  bubo.  Uncleanliness,  long  fore- 
skin, and  long-continued  friction  are  probably,  with  a  certain 
predisposition,  the  causes.  In  the  treatment  it  is  best  to  try 
to  prevent  the  vesicles  from  breaking.     Occasionally,  covering 


VENEREAL   WARTS.  89 

the  patch  with  collodion  will  do  so.  If  not,  or  if  already 
broken,  cleanliness  and  antiseptic  and  astringent  dusting- 
powders  are  to  be  recommended.  In  the  chronic  cases  the 
ulceration  can  be  thoroughly  cauterized  with  nitrate  of  silver 
or  carbolic  acid.  Occasionally,  if  constantly  recurring  on  the 
foreskin,  circumcision  is  to  be  advised,  although,  as  neurotic 
individuals  are  susceptible,  improvement  in  general  health, 
by  hygienic  living,  abstaining  from  sexual  excitement,  alcohol, 
and  tobacco,  may  avoid  some  recurrences. 

Venereal  Warts. 

About  the  glans,  frsenulum,  and  at  the  external  urethral 
orifice  of  the  male  ;  about  the  labia  in  the  female ;  and  in 
other  places,  as  the  anus,  it  is  not  uncommon  to  see  numerous 
pin-head-  and  large-sized  warty  growths.  In  occasional  cases 
the  entire  glans  penis  or  portio  vaginalis  may  be  wholly  lost 
to  view  by  the  enormous  size  to  which  these  growths — called 
variously  condylomata  acuminata,  vegetations,  and  venereal 
warts — attain.  In  the  large  majority  of  cases  there  is  some 
venereal  process  present,  and  the  secretions  from  any  of  these 
have  been  regarded  as  the  cause.  Authentic  cases  in  virgins 
have  been  noted.  Irritating  discharges  appear  to  be  the  etio- 
logic  factor.  Minute  excrescences  appear,  and  their  growth 
is  rapid.  These  are  sometimes  single,  but  usually  multiple, 
and  they  may  be  either  flat  or  pedunculated.  They  consist 
of  papillse,  enormously  elongated,  branching  like  a  tree ; 
vascular,  and  the  whole  may  be  covered  by  many  epithelial 
cells.  Apparently  a  slight  secretion  is  present,  which  causes 
maceration,  giving  off  a  very  disagreeable  odor.  As  yet  no 
cases  of  transmission  by  contact  or  by  inoculation  are  known. 
After  removal  they  frequently  recur.  Occasionally  they  must 
be  differentiated  from  epithelioma  and  condylomata  lata. 
Cleanliness  is  a  prophylactic  measure.  When  small,  if  appli- 
cations of  formalin  or  perchloride  of  iron  solution  are  made, 
the  warts  will  shrivel  and  the  crusts  will  fall  off. 

The  following  application,  made  on  several  successive  days, 
is  satisfactory  : 


90  PHIMOSIS  AND  PARAPHIMOSIS. 

I^     Salicylic  acid,  1.0  gramme; 

Glacial  acetic  acid,          10.0  grammes. 
M.  &  Sig. — For  office  use.     Venereal  warts. 

This  dusting-powder  is  efficacious  : 

3^     Resorcin, 

Salicylic  acid,  aa     1.0  gramme. 

M.  &  Sig. — Apply  locally  with  care. 

It  may  be  dusted  on  the  warts  and  will  cause  them  to  dis- 
appear slowly.  Dilute  nitric  acid  applications  and  dusting 
the  parts  with  calomel  give  good  results.  Simple  excision  of 
the  papillomatous  growth  with  the  base  and  cauterization  of 
the  bleeding  surface  (best  with  the  electrocautery)  is  the 
quickest  and  most  satisfactory  method  of  treatment.  The 
cause,  namely  the  irritating  discharge,  must  be  removed, 
otherwise  a  new  crop  will  certainly  appear. 

Phimosis  and  Paraphimosis. 

Phimosis  is  a  condition  in  which  the  opening  of  the  prepuce 
is  too  small  to  allow  retraction  with  ease  over  the  glans. 
The  degree  of  the  narrowing  of  the  opening  varies  consid- 
erably. This  may  be  either  a  congenital  one  or  an  origi- 
nally sufficiently  large  opening  reduced  to  abnormally  small 
size  by  inflammatory  processes.  This  inflammation  may  be 
due  to  balano-posthitis,  chancroids,  or  other  processes  within 
the  prepuce,  or  the  repeated  formation  of  rhagades  and  sub- 
sequent thickenings  and  rigidity  of  the  preputial  edge  may 
lead  to  phimosis.  The  consequences  of  this  condition  may 
be  the  impairing  of  the  urinary  flow,  and  if  the  opening  is 
pin-head  in  size,  the  urine  then  often  fills  the  preputial  sac, 
also  the  retention  of  the  smegma,  while  infectious  diseases 
of  the  prepuce  are  brought  under  unfavorable  condition  for 
treatment  and  cure.  In  order  to  relieve  this  condition  we 
have  to  resort  either  to  systematic  dilatation  or  to  operative 
interference.  The  dilatation  may  be  used  to  advantage  in 
children  by  inserting  gauze  wicks  or  tents  into  the  prepu- 
tial  sac.     But  there   is   always  some  danger  of  provoking 


PHIMOSIS  AND  PARAPHIMOSIS.  91 

masturbation  by  the  prolonged  irritation.  Ordinary  artery 
forceps  or  forceps  made  for  this  purpose  can  be  used  daily  for 
a  short  period  of  time  until  the  desired  results  are  obtained. 
The  cutting  operation  may  either  be  an  arc-shaped  incision 
from  the  preputial  edge,  so  as  to  enlarge  the  circumference  of 
the  opening  by  stitching  the  lips  of  the  wound  together,  or 
the  prepuce  is  split  over  its  edge  down  to  the  coronary  groove. 
This  is  done  in  the  following  way  :  A  grooved  staff  is  intro- 
duced in  the  dorsal  part  of  the  sac,  and  the  prepuce  split  by 
running  a  bistoury  down  in  the  groove  of  the  staff,  or  by 
using  a  pair  of  scissors  in  the  same  way.  Care  must  be 
taken  to  split  the  inner  part  of  the  prepuce  fully  down  to  the 
angle  of  the  wound.  After  this  is  done,  the  external  lamella 
is  stitched  to  the  internal,  so  that  a  V-shaped  cleft  is  formed, 
or  a  partial  or  total  resection  of  the  prepuce  may  be  done 
after  the  splitting  incision  has  been  made.  We  then  follow 
with  a  circular  incision  at  the  desired  point,  and  again  unite 
both  wound-lips  together.  The  former  is  simply  a  dorsal 
incision,  and  the  latter  are  called  circumcisions. 

Inflammatory  phimosis  maybe  only  transitory  in  character. 
If  chronic,  it  may  become  permanent.  The  cause  must  always 
be  treated.  The  preputial  sac  should  be  continually  irrigated 
with  mild  antiseptic  solution,  and  if  due  to  hard  or  soft 
chancre,  should  be  treated  accordingly.  Besides,  moist  dress- 
ings should  be  constantly  applied. 

Paraphimosis. — This  is  the  condition  in  which  the  prepuce 
is  brought  back  behind  the  glans  and  is  too  tight  to  be 
replaced.  By  the  constriction  of  the  glans  venous  engorge- 
ment takes  place,  which  makes  the  replacement  more  difficult, 
and  if  the  incarceration  persists  for  some  time,  gangrene  may 
result.  This  condition  can  be  relieved  either  by  manipula- 
tions of  various  kinds  or  by  operation.  The  impacted  pre- 
puce may  often  be  replaced  by  taking  the  glans  penis  between 
the  index  and  middle  fingers,  while  the  thumbs  are  placed 
on  the  top  of  the  glans,  and  in  pressing  down  on  the  glans 
try  to  reduce  its  volume,  while  at  the  same  time  the  other 
fingers  try  to  push  or  pull  the  prepuce  forward.  If  this  is 
unsuccessful,  the  prepuce  must  be  incised  over  the  incarcera- 


92  INFECTIONS  AND   TUMORS  OF  PENIS. 

tion  ring  until  the  impaction  is  relieved.  In  case  it  should 
be  necessary,  one  can  proceed  immediately  to  the  resection  of 
the  foreskin. 

Infections  of  the  Penis. 

Phlegmonous  processes  of  the  skin  and  subcutaneous  tissues 
and  lymphangitis  of  the  penis  are  met  with.  The  treatment 
is  by  rest,  sedatives,  warm  moist  applications,  and  surgical 
intervention,  if  necessary.  Chronic  cavernitis  is  shown  by 
swellings  within  the  albuginea,  of  fairly  hard  consistency, 
and  may  be  painful.  Attempts  are  made  at  resorption  with 
moist  packs,  applications  of  tincture  of  iodine,  and  mercurial 
ointment.  Elephantiasis  involving  the  penis  and  prepuce  is 
occasionally  met  with,  usually  following  some  chronic  inflam- 
matory process.  Circumcision  of  the  thickened  prepuce  is  to 
be  advised. 

Tumors  of  the  Penis. 

Cystic  and  hypertrophic  epithelial  tumors  are  seen  occasion- 
ally. The  malignant  tumors  are  of  importance.  Sarcoma 
may  be  either  primary  or  secondary.  The  former  arise 
usually  from  the  erectile  tissues  of  the  penis.  Treatment  is 
the  same  as  for  cancer  of  the  penis — namely,  early  ablation 
of  the  penis  and  adjoining  lymphatic  glands. 

Epithelioma  of  the  Penis. 

It  attacks,  as  a  rule,  the  meatus,  where  mucous  membrane 
and  epidermis  border.  From  this  point  it  spreads  and  may 
involve  the  prepuce.  In  other  cases  its  original  seat  is  on  the 
inner  fold  of  the  prepuce.  It  first  appears  as  a  warty 
excrescence.  This  ulcerates  very  soon  and  covers  itself  with 
a  scab.  The  epithelioma  always  spreads  superficially,  in  the 
course  of  time  covering  and  destroying  quite  a  large  area. 
There  are  cases  on  record  in  which  the  entire  external  geni- 
tals and  even  parts  of  the  abdomen  and  thighs  have  been 
involved.  Occasionally  epithelioma  may  cause  severe  arterial 
hemorrhage  by  opening  the  frsenular  artery.  Lymphatics  on 
tlie  dorsum  penis  and  the  glands  in  both  inguinal   regions 


CARCINOMA    URETHRA.  93 

become  enlarged  and  involved  fairly  qnickly,  and  ulcerate 
after  a  certain  length  of  time.  The  treatment  will  be  an 
operative  one  after  the  disease  is  diagnosed.  While  in  quite 
early  cases  the  actual  cautery  may  be  used,  as  a  rule  excision 
of  the  neoplasm  must  be  performed  and  the  glands  removed. 
In  very  extensive  cases  in  which  operative  interference  does 
not  seem  to  be  advisable,  X-ray  therapy  may  probably  be  used 
to  good  advantage. 

Carcinoma  Urethras. 

The  other  form  of  cancer  is  the  carcinoma  of  the  urethra. 
This  can  appear  anywhere  in  the  course  of  the  urethra.  It 
first  manifests  itself  as  an  extremely  hard,  circumscribed  infil- 
tration, which  very  soon  becomes  the  seat  of  lightning  pains. 
This  infiltration  grows  quite  rapidly,  but,  as  a  rule,  does  not 
ulcerate  in  the  early  stages,  while  the  lymphatic  glands  in  the 
groins  soon  become  involved.  If  a  sound  is  introduced  into 
the  urethra,  we  find  that  it  cannot  be  palpated  through  the 
cancerous  infiltration,  thus  showing  the  degree  of  induration. 
This  cancer  spreads  rapidly  into  the  corpora  cavernosa,  so 
that  a  radical  therapy  can  consist  only  in  the  amputation  or 
excision  of  the  penis,  and  in  cases  of  necessity  the  removal  of 
the  swollen  glands. 

Prognosis. — Epithelioma  of  the  penis  is,  comparatively 
speaking,  a  favorable  form  for  radical  cure.  Carcinoma  is, 
compared  to  epithelioma,  less  favorable. 

QUESTIONS  ON  MALFOEMATIONS,  INJURIES,  AND  DISEASES  OF 
THE  PENIS. 

Do  mal  form  ati  Otis  of  the  penis  occur?    If  so,  enumerate  the  more  common. 

What  is  mean-t  by  fracture  of  the  penis  ? 

What  may  contracture  of  the  penis  be  due  to  ? 

What  is  balanitis? 

What  is  posthitis  ? 

What  is  balano-posthitis? 

May  these  be  non-venereal  in  origin  ? 

What  is  the  treatment  for  these  conditions? 

What  is  herpes  progenitalis? 

Describe  the  different  appearances? 

What  are  the  causes? 

What  is  the  treatment  ? 


94  MALFORMATIONS,  INJURIES,   OF  URETHRA. 

Wliat  are  the  venereal  warts? 

Where  may  they  occur  ? 

Are  they  ever  non-venereal  in  origin? 

Do  the  vegetations  ever  reach  any  size? 

Can  they  be  inoculated  ? 

Describe  the  treatment.  What  is  the  most  satisfactory  mode  for  their  re- 
moval ? 

What  is  phimosis  ? 

By  what  condition  is  it  produced  ? 

Is  it  ever  congenital? 

How  would  you  treat  the  condition  ? 

What  is  paraphimosis? 

How  may  it  be  produced  ? 

What  is  meant  by  the  incarceration  ring? 

How  would  you  treat  this  condition  ? 

How  would  you  treat  phlegmonous  processes  of  the  skin  and  the  subcuta- 
neous tissue  of  the  penis  ? 

Does  elephantiasis  of  the  foreskin  ever  occur? 

How  would  you  treat  it? 

Name  the  most  common  tumors  of  the  penis. 

Where  does  epithelioma  of  the  penis  usually  first  make  its  appearance? 

Describe  the  course. 

What  treatment  is  advised  ? 

Do  the  inguinal  glands  ever  become  involved  ?  Does  this  condition  change 
the  therapy  ? 

CONGENITAL    MALFORMATIONS,    INJURIES,   AND 
DISEASES  OF  THE  URETHRA. 

MALFORMATIONS  OF  THE  URETHRA. 

Congenital  malformations  are  not  very  uncommon.  Com- 
plete absence,  double,  and  entire  obliteration  have  been 
noted.  Absence  of  the  urethra  in  the  glans,  stenosis  of  the 
external  urethral  orifice,  strictures  (valve-like,  cylindrical,  or 
of  other  form)  anywhere  in  the  course  of  the  urethra,  are 
occasionally  met.  However,  the  most  common  conditions  are 
epispadias  and  hypospadias.  By  the  former  is  meant  a  con- 
genital opening  on  the  dorsal  surface  of  the  penis,  the  urine 
being  passed  from  this  abnormal  opening.  This  orifice  may 
occur  anywhere  on  the  upper  surface  of  the  penis,  and  is 
usually  accompanied  with  other  malformations.  Hypospadias 
is  the  most  common  of  all  these  abnormalities.  In  these 
cases  the  urine  is  passed  from  an  abnormal  opening  on  the 
lower  surface  of  the  jienis.  For  practical  description  three 
divisions  are  made — viz. : 


INJURIES  AND  DISEASES  OF  THE   URETHRA.         95 

1.  Hypospadias  of  the  glans. 

2.  Penoscrotal  hypospadias. 

3.  Perineoscrotal  hypospadias. 

All  grades  of  different  appearances  occur.  The  treatment 
of  all  the  malformations  is  operative. 

INJURIES  OF  THE  URETHRA. 

These  occur  commonly  during  the  course  of  catheterization, 
and  hemorrhages,  false  passages,  sepsis,  or  urethral  fever  are 
noted.  Fragments  of  stone  after  crushing  operations  occa- 
sionally cause  traumatism.  A  not  infrequent  occurrence  is 
rupture  of  the  urethra  caused  by  a  fall.  These  vary  in  the 
severity  of  their  symptoms  :  the  rupture  may  be  complete  or 
incomplete.  Hemorrhage  from  the  external  urethral  orifice, 
swelling  along  the  course  of  the  urethra,  possibly  inability 
to  pass  urine,  pain,  and  finally  urinary  infiltration,  with  its 
symptoms,  are  to  be  expected.  Most  of  the  cases  require  a 
free  incision  and  drainage,  the  steps  of  the  operation  varying 
as  to  the  severity  of  the  injuries. 

Foreign  bodies  are  met  with  in  the  urethra.  They  may 
arise  within  the  urethra  itself,  as  a  stone,  or  be  introduced 
from  without,  or  reach  some  part  of  the  urethra  from  the 
bladder.  Usually  infection  sets  in,  and  symptoms  then 
depend  on  this  fact.  In  all  cases  it  is  necessary  to  remove 
the  object.  This  may  be  possible  by  the  aid  of  the  urethro- 
scope ;  otherwise  by  an  operation. 

DISEASES  OF  THE  URETHRA. 
Benign  Tumors. 

It  is  necessary  to  mention  papillomata  and  polypi.  The 
former  are  similar  to  condylomata  acuminata,  and  usually 
occur  in  cases  of  gleet ;  they  may  appear  anywhere  in  the 
urethra.  Treatment  is  by  the  aid  of  the  urethroscope,  and 
removal  with  the  galvanocautery."  Polypi  are  occasionally 
met  with^  and  their  treatment  is  the  same. 


96  INFLAMMATIONS  OF  THE   URETHRA. 

Malignant  Tumors. 

These  are  usually  secondary  growths — especially  carcino- 
ma ta. 

Inflammatory  Diseases  of  the  Urethra. 

Whenever  urethritis  is  spoken  of,  an  inflammation  of  the 
urethra  is  meant ;  in  fact,  any  portion  of  it.  It  is  necessary 
to  qualify  according  to  the — 

I.  Cause  :  III.  Duration  : 
Specific.  Acute. 

Non-specific.  Chronic. 

U.  Locality  :  IV.  Infectious  properties  : 
Anterior.  Infectious. 

Posterior.  Non-infectious. 


Specific  Urethritis. 

This  is  caused  by  the  gonococcus  of  Neisser.  Whenever 
present,  it  is  referred  to  as  a  gonorrhoea.  Here  there  is  a 
period  of  incubation.  The  disease  usually  runs  a  varied 
length  of  time,  and  remains  contagious  until  the  gonococcus 
becomes  absent. 

Non-specific  Urethritis. 

By  this  is  meant  an  inflammation  of  the  urethra  caused  by 
other  germs  or  factors  than  the  gonococcus.  In  this  case  the 
cause  may  be  from  without  and  within  the  urethra.  Clini- 
cally, these  cases  may  run  a  course  very  similar  to  a  typical 
gonorrhoea.  For  this  reason,  therefore,  it  is  necessary  to 
resort  to  the  microscope.  There  are  syphilitic,  tuberculous, 
chancroidal,  and  simple  urethritis.  The  first  three  can  readily 
be  diagnosed  by  local  lesions  which  are  present,  and,  of  course, 
by  taking  into  consideration  also  the  general  conditions  of  the 
patient  in  the  cases  of  the  tuberculous  and  syphilitic.  There- 
fore, in  the  cases  of  the  so-called  simple  urethritis,  the  absence 


NON-SPECIFIC  URETHRITIS.  97 

of  the  gonococciis  is  noted,  but  one  or  more  varieties  of  bac- 
teria may  be  found.  Yet  in  certain  other  cases,  where  there 
are  constitutional  affections,  as  gouty  diathesis,  or,  agaiu, 
where  there  are  mechanical  or  chemical  irritations,  these  may 
be  the  causes,  and  in  these  cases  there  can  be  a  complete 
absence  of  any  germs. 

The  highly  acid  vaginal  secretion  of  some  women  just  before 
and  during  the  menstrual  flow  has  been  Jcnoivn  to  cause  icrethrifis. 
Hence  in  married  persons  careful  inquiry  should  be  made  to 
elicit  the  relation  in  time  between  an  intercourse  and  the  men- 
strual period,  and  so  avoid  the  certainty  of  reflecting  upon  the 
vhiue  of  the  wife. 

From  what  has  been  said  it  can  be  inferred  that  because  a 
patient  presenting  himself  for  examination  suffers  from  an 
intense  urethral  discharge,  such  a  patient  does  not  necessarily 
suffer  from  gonorrhoea.  80  an  injustice  can  occasionally  be 
done  if  every  discharge  is  pronounced  as  gonorrhceal.  For 
this  reason,  if  for  no  other,  it  is  necessary  to  impress  upon 
every  one  the  importance  of  a  microscopical  examination,  and 
even  a  bacteriological  examination  in  doubtful  cases. 

In  the  specific  urethi^itis  it  is  obligatory  to  find  the  gonococcus 
of  Neisser.  There  are  other  diplococci  that  resemble  this  specific 
germ,  and  they  are  referred  to  as  pseudogonococci.  WJien  it 
comes  to  a  differentiation  of  these  it  is  necessary  to  go  into  minute 
bacteriological  examination. 

A  few  facts  concerning  the  gonococcus  are  :  It  was  discov- 
ered by  Neisser  in  1879 ;  first  cultivated  by  Bumm  in  1895 ; 
its  microscopical  appearances  are  not  entirely  characteristic  ; 
it  stains  with  basic  aniline  dyes ;  it  is  negative  to  Gram's 
stain  ;  is  found  within  the  protoplasm  of  the  pus-cells,  and 
does  not  grow  on  the  ordinary  culture-media.  The  gonococci 
remaining  in  the  urethra  after  a  gonorrhcea  may  lie  dormant 
there  and  remain  harmless  for  years,  yet  when  transplanted  on 
to  another  urethra,  may  cause  an  intense  acute  gonorrhcea. 
Flattened  epithelial  cells  seem  to  protect  against  infection 
better  than  columnar  epithelium.  Immunity  does  not  follow 
infection.  No  successful  attempts  are  recorded  of  the  inocu- 
lation of  the  gonococcus  in  lower  animals, 
7— V.  D, 


98  GONOBRHCEA. 

The  Three  Differential  Diagnostic  Points  of  the  Gonococcus 
Morphology : 

1.  It  must  he  distinctly  a  biscuit-shaped,  rather  small  diplo- 
coccus,  and  is  never  single. 

2.  It  must  decolorize  by  Gramas  method. 

3.  It  must  be  within  the  cell-bodies  of  pus-  and  epithelial- 
cells,  both  of  which  are  very  abundant  in  a  given  discharge,  both 
with  and  without  these  cocci. 

Gonorrhoea, 

In  gonorrhoea  there  is  a  period  of  incubation.  In  most 
cases  it  is  from  three  to  seven  days.  Periods  of  less  than 
three  and  more  than  seven  days  are  comparatively  rare, 
although  there  are  some  authentic  cases  where  the  period  of 
incubation  has  also  run  up  as  high  as  twenty-one  days.  The 
average  period  is  five  days. 

Abortive  Treatment. — Knowing,  then,  that  such  a  period 
exists,  it  is  necessary  to  consider  at  this  point  the  so-called 
abortive  treatment.  A  local  application  that  will  meet  the 
three  requirements  of  Neisser — that  is  :  (1)  A  remedy  that 
will  destroy  the  gonococcus ;  (2)  leave  the  mucous  membrane 
uninjured ;  (3)  not  increase  the  inflammation — has  as  yet  not 
been  found.  For  this  reason,  and  vnth  these  three  objects  in 
mind,  there  is  no  good  abortive  treatment  for  gonorrhoea.  This 
is  very  important  to  know.  Nevertheless,  there  are  certain 
things  that  can  be  done. 

One  of  the  most  effective  agents  is  nitrate  of  silver — viz.  : 

^     Nitrate  of  silver,  1 .0  gramme  ; 

Distilled  water,  30.0  grammes. 

M.  &  Sig. — For  office  use. 

A  few  drops  are  to  be  instilled  into  the  urethra  and 
along  the  frsennlum  as  soon  after  suspicious 
intercourse  as  possible. 

A  more  or  less  violent  reaction  follows,  with  destruction 
of  the  outer  epithelium,  a  very  purulent  discharge,  and  even 


GONOBBHCEA.  99 

slight  hemorrhage  may  occur  in  a  few  hours  by  using  this 
instillation.  Whenever  such  a  course  is  advised,  it  is  neces- 
sary to  state  what  may  be  expected,  although  there  are  many 
cases  where  the  reaction  is  slight.  If  it  does  cause  any 
trouble,  give  the  patient  rest,  light  diet,  laxatives,  alkalines. 
Other  solutions  are  also  employed.  They  are  the  newer 
silver  salts,  such  as  protargol,  largin,  argonin,  and  nargol. 

I^     Protargol,  5.0  grammes  ; 

Glycerin,  10.0        " 

Distilled  water,  q.  s.  ad  20.0        " 

M.  &  Sig. — For  office  use. 

Protargol  or  any  one  of  the  foregoing  newer  silver  salts  in 
solution  can  be  used  as  the  nitrate  of  silver  solution.  Usually 
the  reaction  is  light. 

Prophylactic  Treatment. — It  is  the  duty  of  every  physician 
to  warn  both  sexes  of  the  gravity  of  venereal  infection.  In- 
cluded in  this  is  the  most  common  of  venereal  diseases — i.  e., 
gonorrhoea.  Gonorrhoea  is  found  in  both  sexes  and  in  all 
ages ;  most  commonly  in  men  between  the  ages  of  twenty  and 
thirty,  and  oftentimes  seen  in  infants,  and  decreasing  in  fre- 
quency with  advancing  age. 

Gonorrhoea  may  be  acquired  in  other  ways  than  in  sexual 
contact.  It  is  a  fact  that  the  gonococcus  may  retain  its 
vitality  when  under  certain  conditions  of  heat  and  moisture 
for  some  hours,  and  in  this  way,  by  transference  by  towel  or 
washing,  innocent  persons  may  be  infected. 

If  it  is  the  first  attack,  and  the  presence  of  the  gonococcus 
established,  it  is  an  acknowledged  fact  that  the  gonococcus 
found  its  introduction  into  the  urethra  at  the  meatus.  It  is 
known  that  this  specific  germ  does  not  remain  on  the  surface 
of  the  mucous  membrane,  but  while  propagating,  it  apparently 
passes  into  and  underneath  the  epithelium — usually  not  deeper, 
but  cases  have  shown  that  the  gonococcus  has  been  found 
even  in  the  sheath  of  the  penis. 

It  is  the  proliferation  of  the  gonococcus  among  the  epithe- 
lial cells  in  three  to  seven  days  which  sets  up  the  character- 


100  GONORRHCEA. 

istic  inflammatory  reaction.  Blood-vessels  become  engorged, 
and  lymph  and  leucocytes  are  poured  out.  Some  investigators 
believe  that  these  leucocytes  absorb  the  gonococci,  besides 
loosening  the  epithelium,  and  the  pus  in  this  Tvay  escaping, 
the  disease  thus  heals  itself.  The  new  epithelium  thus  formed 
does  not  contain  all  the  elements  capable  of  propagating  the 
gonococci  that  the  original  did.  When  the  gonococci  are 
being  eliminated  in  greatest  numbers  the  discharge  is  at  its 
maximum,  and  we  find  desquamated  epithelial  cells  and  pus- 
corpuscles  loaded  with  the  gonococci. 

With  the  elimination  of  the  germs  the  discharge  decreases. 
From  being  purulent  it  changes  to  watery  and  colorless,  and 
we  find  pus  and  epithelial  cells  in  varying  numbers.  This 
often  makes  its  appearance  in  the  urine  as  threads.  The  con- 
tagiousness is  not  always  lost  when  the  discharge  disappears, 
but  often  remains  as  long  as  any  threads  or  even  pus-corpuscles 
remain  in  the  urine. 

Symptoms  of  Acute  Anterior  Gonorrhoea : 

Commences  at  meatus. 

Inoculation  of  gonorrhceal  pus  is  the  cause. 

Incubation  period  is  from  three  to  seven  days. 

CEdema  of  meatus. 

Swelling  of  orifice. 

Color,  pale  pink. 

Peculiar  sensation  at  meatus :  between  tickling  and  itching. 

Patient  keeps  his  mind  fixed  on  genitalia,  and  therefore 
is  obliged  to  empty  bladder. 

Ardor  urinse. 

Lips  sealed  first  day. 

Second  day,  purulent  discharge,  increasing  daily. 

Second  week,  pus  is  greenish-yellow. 

If  inflammation  is  high,  erections  are  painful.  Here  the 
inflammation  has  extended  down  the  glands  and  minute 
ducts  between  meshes  of  the  corpus  spongiosum,  and 
does  not  allow  distention  by  the  blood  when  influx 
occurs  at  the  time  of  erection.  Therefore  the  organ 
is  not  uniformly  distended  and  acts  like  a  bow  where 


THE  EXAMINATION  OF  THE  DISCHARGE.  101 

agglutination  exists  in  the  urethra ;  therefore  the  cur- 
vature, called  choy^dee,  results. 
Painful  erection  especially  common  in  third  week. 
Slight  hemorrhage  from  urethra. 
Inflammatory  symptoms  gradually  subside. 
Diagnosis, — Examination  of  the  discharge  will  often  distin- 
guish   it    from   syphilitic,  tuberculous,   chancroidal,  pseudo- 
gonococcus,  simple  and  non-specific  urethritis. 

Diiferential  diagnosis  from  recurrent  attacks  due  to  stricture, 
chronic  localized  areas  of  inflammation,  prostatitis,  etc.,  must 
also  be  made. 

The  Examination  of  the  Discharge. — For  routine  work  it  is 
best  to  smear  a  very  thin  layer  of  the  pus,  squeezed  from  the 
deep  part  of  the  urethra,  and  taken  with  a  platinum  needle  on 
a  slide ;  fixing  by  passing  through  a  flame,  and  then  staining 
with  Loeffler's  methylene-blue  solution,  methylene-violet,  or 
gentian-violet  solution.  These  may  be  of  varying  strength, 
yet  it  is  best  to  adhere  to  a  solution  made  according  to  a 
definite  formula : 

Loeffler's  methylene-blue  solution: 

Saturated  alcoholic  solution  methylene- 
blue,  30.0  c.c. 
Solution  caustic  potash  in  water,  1 :1000,  100.0    " 

Ehrlich's  aniline  gentian-violet  solution  : 

Saturated  alcoholic  solution  of  gentian- 
violet,  16.0  c.c. 
Aniline  water,                                                84.0    " 

In  all  doubtful  cases  the  Gram  stain  is  to  be  recommended. 
The  specimen  is  prepared  in  a  manner  as  described  above,  and 
then  stained  for  three  minutes  in  a  saturated  solution  of  gen- 
tian-violet in  aniline  water.  (In  a  rough  manner,  about  1  c.c. 
of  aniline  oil  with  15  c.c.  of  distilled  water  are  thoroughly 
shaken  in  a  test-tube,  then  filtered,  and  a  saturated  alcoholic 
solution  of  gentian-violet  added,  drop  by  drop,  until  the  least 
opalescence  occurs.     Then  this  should  be  filtered.)     Without 


102     TREATMENT  OF  ACUTE  ANTERIOR   GONORRHCEA. 

washing  off,  but  after  simply  taking  off  the  excess  of  staining 
fluid  with  blotting-paper,  place  the  specimen  into  solution  of — 


^ 

Iodine, 

1.0  c.c. 

Potassium  iodide, 

2.0    " 

Water, 

100.0    " 

for  from  one  to  two  minutes.  The  specimen  becomes  black. 
Remove  excess  with  filter-paper.  Next  place  in  alcohol,  and 
keep  there  until  no  more  stain  can  be  removed.  Then  wash 
with  distilled  water,  and  counter-stain  with  a  0.25  per  cent, 
aqueous  solution  of  Bismarck  brown.  Wash,  dry,  and  exam- 
ine direct,  after  placing  a  small  drop  of  cedar  oil  on  the 
specimen,  with  immersion  lens.  The  gonococcus  loses  its 
stain  and  takes  the  brown  color.  Any  diplococci  remaining 
blue  are  not  gonooocci. 

The  gonococcus  has  a  shape  like  a  coffee-bean,  and  always 
appears  in  pairs  whose  flattened  surfaces  are  together.  In 
reproduction,  each  individual  divides  into  two  at  right  angles 
to  the  flattened  surface.  The  gonococcus  may  be  between  and 
upon  epithelial  and  pus-cells,  and  characteristically  in  the  pus- 
ceil. 

The  three  diagnostic  points  of  the  gonococcus  are  there- 
fore— 

1.  Decolorizing  with  Gram's  stain  as  above. 

2.  Characteristic  diplococcus  {^'hiscuif  form). 

3.  Presence  in  the  epithelial  and  pus-cells. 

Course. — The  duration  was  formerly  six  to  eight  weeks,  but 
now  less  in  very  carefully  treated  cases,  depending  upon  the 
method  of  treatment  used. 

Treatment  of  Acute  Anterior  Gonorrhoea. — No  matter  what 
the  day  since  the  commencement  of  the  discharge,  we  can 
immediately  commence  local  treatment.  It  is  but  just  to  state 
that  there  have  been  innumerable  methods  and  systems  for 
the  treatment  of  this  disease,  and  therefore  we  can  infer  that 
no  one  is  eminently  satisfactory.  Many  have  put  the  patient 
in  terrible  agony,  and  have  left  the  sufferer  worse  off  than 
without  treatment. 


TREATMENT  OF  ACUTE  ANTERIOR   GONORRH(EA.    103 

In  the  treatment  of  acute  anterior  gonorrhoea  it  is  necessary 
to  consider  these  points  : 

I.  General  Aims. — 1.  To  remove  the  gonococci.  2.  To 
see  that  the  patient  does  not  suffer.  3.  To  avoid  any  com- 
plications. 

II.  Hygienic  Management. — 1.  Regularity  of  life. 
2.  Rest — lying  down,  rather  than  walking,  etc.;  no  exercise; 
not  too  much  sleep. 

III.  Diet. — Moderate  amount.  Bland  and  non-stimulat- 
ing. Milk,  by  preference.  If  debilitated,  meats,  and  even 
red  wines — claret.  Avoid  greasy  food,  pastry,  spices,  pickles, 
acids ;  also  liquor,  coffee,  tea.  Water,  in  large  quantities,  is 
to  be  taken.     Smoking  not  objectionable  in  moderation. 

IV.  General. — No  sexual  excitement,  active  or  passive. 
Penis  should  be  kept  clean  ;  handled  as  little  as  possible. 
Suspensory  bandage  is  a  preventive  of  orchitis,  etc.  Gonor- 
rhoea! bag  aids  in  keeping  the  parts  clean.  Great  care  is 
necessary  not  to  get  pus  into  the  eye  nor  transmit  it  to  others. 

V.  Prophylaxis. — Soiled  dressings  of  the  penis  should  be 
burned  ;  towels  and  underwear  carefully  boiled  by  themselves 
if  possible. 

YI.  Internal  Treatment. — The  remedies  that  can  be 
given  internally  for  acute  gonorrhoea  are  divided  into  several 
classes.  Oftentimes  alkalies  and  diuretics  are  given  to  render 
the  urine  bland  and  non-irritating.  Oils  like  sandalwood  and 
balsams  are  given,  so  that  the  substances  into  which  they  divide 
will  act  favorably  upon  the  mucous  membrane  as  the  urine 
passes  from  the  bladder ;  they  also  have  a  tendency  to  act  on 
the  urine.  Sedatives  and  anodynes  likewise  are  given  to  les- 
sen burning  on  urination  and  chordee.  With  these,  practically 
all  the  symptoms  arising  from  acute  gonorrhoea  can  be  con- 
trolled. There  is  another  division  that  is  of  great  importance, 
but  it  is  used  to  keep  the  urine  as  antiseptic  as  possible — viz., 
the  ordinary  urinary  antiseptics. 

Following  these  principles,  the  patient  should  pass  large 
quantities  of  urine ;  it  should  be  feebly  alkaline  or  just  neu- 
tral, so  that  it  is  bland  and  non-irritating  to  the  raucous 
membrane.     If  the  patient  won't   take   large   quantities  of 


104    TREATMENT  OF  ACUTE  ANTERIOR   GONORRHCEA. 

fluids,  it  is  often  necessary  to  give  alkalies  or  alkaline  diu- 
retics, the  best  probably  being  citrate  of  potassium,  usually 
given  in  10-  or  15-grain  doses,  always  with  a  large  quantity 
of  fluid. 

As  to  balsams  and  the  sandalwood  oil.  The  result  sought 
is  to  give  an  alleviating  and  bland  action  to  the  mucous  mem- 
brane of  the  urethra  by  the  urine.  The  sandalwood  oil  is 
valuable,  and  to  get  its  action  it  should  be  given  in  fairly 
large  quantities,  say  10  minims  four  or  five  times  a  day,  in 
capsules,  emulsions,  or — 

I^     Olei  santali,  10.0  grammes  ; 

Olei  menthse  pip.,  0.5  gramme. 

M.  &  Sig. — Ten  minims  on  sugar  every  three  hours. 

Or  in  connection  with  an  alkaline  salt,  so  that  possibly  the 
reaction  in  the  urethra  is  still  more  bland  than  if  given  with- 
out the  addition  of  an  alkali.  Oftentimes  if  sandalwood  oil 
in  capsules  cannot  be  had,  a  very  good  way  is  to  prescribe  it 
in  connection  with  a  little  oil  of  peppermint,  as  shown  in  the 
above  prescription. 

There  are  any  number  of  combinations  that  can  be  given 
in  connection  with  sandalwood  oil. 

^     Olei  santali,  10.0  grammes  ; 

Liq.  potassii,  15.0         " 

Syrupi  acacise,  40.0         " 

Aq.  menth.  pip.,  q.s.  ad  120.0         " 

M.  &  Sig. — Teaspoonful  every  three  hours. 

It  is  not  necessary  to  remember  the  exact  amount  as  stated 
in  the  preceding  formula,  but  to  grade  the  amount  according 
to  the  necessity  of  each  case.  If  there  is  great  pain  during 
urination,  use  this  form.  If  it  is  not  so  painful,  then  decrease 
the  amount. 

The  oil  of  sandalwood  is  especially  used  in  the  beginning 
of  a  gonorrhoea ;  it  is  soothing,  lessens  pain  along  the  ure- 
thra, and  diminishes  discharge. 

Balsam  of  copaiba  and  cubebs,  etc.,  are  given  usually  in  the 


TREATMENT  OF  ACUTE  ANTERIOR   GONORRHCEA.   105 

later  stages  of  gonorrhoea.  Balsam  of  copaiba  was  formerly 
regarded  as  the  specific  in  a  gonorrhoea  that  had  lasted  for  a 
considerable  time,  especially  in  connection  with  alkaline  diu- 
retics. All  these  have  a  disagreeable  taste,  and  the  object 
should  be  to  cover  up  such  taste. 

In  the  later  stages  of  inflammation  the  following  formula 
will  be  found  rather  reliable  : 


Bals.  copaibse, 

30.0  grammes ; 

Liq.  potassse, 
Syrupi  tolutani, 
Ext.  glycyrr.  fl., 
Aquas,  q.  s.  ad 

15.0 

30.0         " 

30.0         " 

120.0         " 

M.  &  Sig. — Teaspoonful  three  to  five  times  daily. 

Cubebs  is  available  in  the  declining  stage — oleoresin  of 
cubebs,  10  minims  in  each  capsule,  given  four  or  five  times 
a  day.     We  often  see  this  stimulate  digestion. 

Aminoform,  cystogen,  methylene-blue,  salol,  and  urotropin 
are  urinary  antiseptics.  Methylene-blue  causes  the  urine  to 
turn  blue,  and  it  is  best  to  mention  this  to  the  patient.  It  is 
given  in  0.05  to  0.1,  the  other  antiseptics  in  0.25  to  0.5 
gramme  doses,  three  or  four  times  a  day. 

The  Lafayette  Mixture  is  an  excellent  urethral  and  vesical 
tonic  and  has  the  following  composition  : 


Bals.  copaibse, 
Liq.  potassse, 
Spts.  setheris  comp., 
Tinct.  lavand.  comp., 

25.0  grammes ; 
15.0         " 
20.0         " 
15.0         " 

Syrupi  simplicis, 
Aquae,  q.  s.  ad 

120.0         " 

M.  &  Sig. — Tablespoonful  q.  i.  d. 

The  following  paste  may  often  be  of  service : 

I^     Pulv.  cubebse,  15.0  grammes ; 

Bals.  copaibse,  q.  s. 
M.     Fiat  massa. 
Sig. — Bolus  every  three  hours. 


106     TREATMENT  OF  ACUTE  ANTERIOR   GONORRHCEA. 

In  cases  where  the  urine  burns  on  passing  through  the 
urethra — ardor  iLrince — and  in  chordee  other  measures  must  be 
adopted — that  is,  sedatives  or  opiates  must  be  used.  In 
practice  it  is  found  that  codeine  controls  chordee,  0.015 
gramme  three  to  five  times  a  day ;  or  perhaps  larger  doses, 
especially  at  night. 

If  the  patient  cannot  sleep  on  account  of  erections  : 

^     Phenacetini,  3.0  grammes ; 

Sacchar.  lactis,  3.0        " 

M.  et  div.  in  pulv.  No.  x. 
Sig. — Two  or  three  each  night  if  necessary. 

I^     Codeinse  phosphatis,         1 5.0  grammes 
Ol.  santali,  15.0        " 

Tinct.  hyoscyamit,  10.0        " 

Liq.  potassse,  10.0        " 

Syr.  acaciae,     q.  s.  ad      90.0        " 

M.  &  Sig. — One  teaspoonful  three  or  four  times  daily. 

Perhaps  one  need  not  give  any  medication  during  the  day, 
but  something  like  this  at  night: 

I^     Potassii  bromidi,  30.0  grammes  ; 

Codeinse  phosphatis,  0.5  gramme  ; 

Tinct.  hyoscyami,  25.0  grammes ; 

Aq.  camphorse,  240.0        " 
M.    Fiat  solutio. 
Sig. — One  tablespoonful  with  water  two  or  three 

times  in  the  evening. 

VIL  Local  Treatment. — The  bacterial  and  the  anti- 
phlogistie  methods.  If  success  is  desired,  it  is  necessary  to 
give  particular  attention  to  the  local  treatment.  There  are 
different  views  on  the  subject  of  local  treatment.  For  in- 
stance, those  who  follow  the  so-called  Neisser  school  (bacterial 
view),  having  for  their  object  the  elimination  of  the  gono- 
coccus,  commence  the  local  treatment  at  once. 

Ever  since  the  gonococcus  has  been  known  to  be  the  cause 


TREATMENT  OF  ACUTE  ANTERIOR    GONORRHCEA.    107 

of  gonorrhoea  the  silver  salts  have  practically  been  considered 
to  have  a  selective  action  on  them.  Some  of  these  salts  and 
their  percentage  equivalent  of  silver  are  : 

Argonin,         4  per  cent,  of  silver. 
Protargol,       8  "  " 

Largin,  10         "  " 

Nargol,  10         "  " 

Albargin,      15         "  " 

Ichthargan,  30         "  " 

The  other  school  advocates  the  so-called  antiphlogistic  treat- 
ment of  Fournier.  Absolutely  no  local  treatment  is  given  in 
the  early  stage.  So  long  as  the  acute  symptoms  run  high, 
diuretics  and  diluents  are  relied  on — nothing  is  prescribed 
locally  to  restrict  the  discharge.  Then  the  local  treatment  is 
commenced. 

These  two  treatments  have  been  combined,  but  the  school 
of  Fournier  does  not  take  into  consideration  the  presence  of 
the  gonococcus,  but  only  the  symptoms. 

JMien  local  treatment  is  adopted,  it  is  necessary  to  consider 
the  individual  case  and  vary  the  treatment  according  to  the  in- 
tensity of  the  inflammation. 

The  medicinal  agents  used  in  injection  and  application  have 
three  different  actions — viz.  : 

1.  Germicidal. 

2.  Astringent. 

3.  Stimulating. 

There  are  different  modes  of  application — viz.: 

1.  Injections. 

2.  Irrigations. 

3.  Instillations. 

4.  Soluble  bougies. 

5.  Salves. 

6.  Direct  application  of  electrolysis,  etc.,  with  the  aid 

of  the  urethroscope. 


108     TREATMENT  OF  ACUTE  ANTERIOR   GONORRHCEA. 

Having  established  the  presence  of  the  gonococcus,  and 
considered  it  best  to  give  local  treatment,  a  decision  must  be 
then  made  as  to  the  method  of  application  :  whether  or  not 
S)nall  injections,  given  by  the  physician  at  first  and  then, 
after  suitable  personal  instruction,  by  the  patient,  or  irriga- 
tions, given  by  the  physician,  are  to  be  advised ;  selection  of 
the  drug  must  be  made  with  special  reference  to  the  action 
sought.  If  a  follower  of  the  school  of  Neisser,  which  teaches 
that  the  presence  of  the  gonococcus  is  the  important  factor, 
one  of  the  so-called  "  newer "  silver  salts  must  be  used. 
There  can  be  no  hesitation  in  saying  that  if  the  methods 
of  the  Neisser  school  are  used,  the  best  results  are  observed. 
For  this  reason  it  cannot  be  advocated  too  strongly.  The 
following  is  a  classification  of  the  different  remedies  with 
their  action : 


11. 


III. 


PuEE  Antiseptics 
NOT  Astringent. 

Argonin. 

Protargol. 

Largin. 

Nargol. 

Ichthargan. 

Albargin. 

Citrate  of  silver. 

Ichthyol. 


Antiseptics  Slightly 
Astkingent. 

Nitrate  of  silver. 
Argentamin. 
Potassium  perman- 
ganate. 


PUEE   ASTEINGENTS. 

Zinc  sulphate. 

Zinc  sulphocarbolate. 

Alum. 

Subacetate  of  lead. 


Neisser's  plan  for  using  these  silver  salts  is  laid  down  in  a 
few  rules — viz.: 

1.  These  salts  are  begun  as  soon  as  the  presence  of  the 
gonococcus  is  established. 

2.  A  daily  microscopical  examination  must  be  made  in 
order  to  ascertain  if  the  gonococcus  is  present  or  absent. 
After  its  absence  for  days,  a  slightly  stimulating,  antiseptic, 
and  astringent  remedy,  such  a,s  nitrate  of  silver,  may  be 
used. 


METHOD   OF  INJECTION.  109 

The  disadvantages  of  silver  nitrate  are  : 

1.  It  stains  linen  and  skin. 

2.  It  is  irritating,  slightly  in  most,  markedly  in  a  few,  cases. 

3.  It  precipitates  albumin,  thus  limiting  its  range. 

4.  It  does  not  penetrate  the  tissues. 

Citrate  of  silver  and  argentamin  are  less  irritating  and  more 
efficacious  in  certain  cases. 

Method  of  Injection. — In  order  to  commence  this 
treatment,  prescribe  0.25  to  0.5  per  cent,  solution  of  the  newer 
silver  salts.  These  are  to  be  used  for  a  few  days,  and  if  the 
patient  is  not  sensitive,  they  should  be  increased  in  the  course 
of  from  seven  to  ten  days,  to  even  as  high  as  2  or  3  per  cent. 
The  patient  should  urinate  previous  to  every  injection ;  then 
sit  down  and  inject  10  or  15  c.c,  according  to  the  quantity 
that  the  anterior  urethra  will  hold.  Several  times  a  day  the 
injected  quantity  should  be  held  in  at  least  ten  minutes ;  at 
other  times  not  less  than  three  minutes  each  time,  and  the 
number  of  times  injected  should  be  from  eight  to  twelve — 
on  the  average  every  two  to  three  hours.  After  the  gono- 
coccus  has  remained  absent  under  this  treatment  for  three  to 
five  days  or  even  longer,  the  remedies  in  group  II.  can  be 
commenced — namely,  those  which  combine  antiseptic  and 
astringent  effect.  • 

I^     Potassii  permang.,  0.12  gramme  ; 

Aquae  destillatse,  120.00  grammes. 

^     Argenti  nitratis,  0.10  gramme  ; 

Potassii  permang.,  0.25        " 

Aquae  destillatae,  150.00  grammes. 


Or- 


I^     Argentamini,  0.1  gramme  ; 

Aquse  destillatae,  100.0  grammes. 


These  are  to  be  used  from  three  to  five  times  a  day.  It  is 
not  necessary  to  retain  them  in  the  urethra  more  than  a  few 
seconds.     As  to  how  long  a  period  this  second  group  should 


no  FOUBNIER  METHOD. 

be  used  is  regulated  by  the  microscopical  findings  or  the 
presence  of  considerable  numbers  of  epithelial  cells. 

After  this  the  use  of  the  astringents  in  the  third  group  is 
commenced : 

^     Zinci  sulphatis,  0.25  gramme ; 

Liq,    plumbi   subacet. 

dil.,  120.00  grammes. 

^     Zinci  sulphocarboL,  0.35  gramme; 

Aquse  destillatte,  120.00  grammes. 

These  are  used  two  or  three  times  each  day  in  the  same 
manner  as  those  in  group  II, 

FouENiER  Method. — If  this  is  adopted,  the  local  treat- 
ment is  not  commenced  until  the  stage  of  decline  has  set  in. 
Then  the  following  injections  are  used,  as  already  described  : 

I^     Berberin^     hydrochlo- 

ratae,  0.25  gramme ; 

Aquse  destillatse,  100.00  grammes. 

^     Zinci  sulphocarbolatis,       0.35  gramme  ; 
Aquse  destillata?,  120.00  grammes. 

^     Zinci  sulphatis,  0.25  gramme ; 

Liq.    plumbi    subacet. 

dil.,  120.00  grammes. 

Ricord's  Mixture : 

I^     Zinci  sulphatis,  0.50  gramme ; 

Plumbi  acetatis,  0.25         " 

Aquse  destillatse,  120.00  grammes. 

Sig. — Shake  before  using. 

I^     Zinci  sulphatis,  0.25  gramme ; 

Bismuthi  sul)nitratis,          8.00  grammes  ; 
Pulveris  acacife,  4.00         " 

Aquae  destillatffi,  q.  s.  ad  120.00         " 


METHOD   OF  IRRIGATION.  Ill 

^     Zinci  sulphatis,  0.25  gramme  ; 

Ext.  hydrastis  fl.,  10.00  grammes; 

Aquse  destillatse,  q.  s.  ad  1 20.00  " 

The  hydrastis  stains  the  clothes  yellow. 

Ultzmann's  Mixture : 

I^     Aluminis, 

Zinci  sulphatis, 

Acidi  carbolici,  aa     0.25  gramme  ; 

Aquse  destillatse,  120.00  grammes. 

Method  of  Irrigation. — The  irrigation  method  of  treat- 
ment has  long  been  advocated.  Janet,  in  1890,  again  brought 
it  forward,  and  since  then  it  has  been  greatly  modified,  ^.s' 
now  recommended,  it  consists  of  irrigating  only  the  anterior  ure- 
thra, in  a  case  of  anterior  urethritis,  in  the  following  manner,  with 
the  necessary  'apparatus  : 

An  irrigator  of  any  pattern  which  can  be  raised  and  low- 
ered, connected  with  rubber  tubing  of  at  least  1.5  centimeter 
diameter  and  about  two  meters  long.  At  the  end  a  stop-cock 
of  some  kind  is  attached,  just  back  of  a  nozzle  of  varying 
shape,  which  can  be  adjusted  to  the  external  urethral  orifice. 
If  a  case  is  presented  for  treatment,  no  matter  whether  the 
gonococcus  is  present  or  absent,  the  treatment  can  at  once  be 
commenced.  It  is  necessary,  however,  to  consider  the  medi- 
cation, the  quantity  to  be  used,  also  the  frequency,  the  height 
at  which  the  fluid  should  be  placed,  and  other  details.  If 
the  treatment  is  not  carefully  undertaken,  the  objects  that 
are  claimed  for  it  are  not  obtained.  Advocates  believe  that 
the  length  of  time  for  the  cure  of  a  case  of  gonorrhoea  is 
shortened,  and  that  the  complications  are  lessened.  The 
technique  is  as  follows  : 

1.  Have  patient  sit  in  an  ordinary  arm-chair,  or  semiprone 
or  flat  on  the  back. 

2.  Cleanse  the  external  urethral  orifice. 

3.  Protect  patient  with  towels,  and  place  a  douche-pan  so 
as  to  re-ceive  the  fluid  as  it  comes  from  the  external  urethral 
orifice. 


112  ACUTE  POSTERIOR    URETHRITIS. 

4.  If  an  acute  case  of  gonorrhoea,  with  no  complications, 
place  irrigator  about  one  meter  above  the  part  to  be  irrigated, 
and  use  a  warm  0.1  to  0.2  per  cent,  solution  of  the  newer 
silver  salts,  taking  about  1000  c.c.  for  each  irrigation,  which 
is  to  be  done  not  too  slowly.  The  fluid  should  pass  into  the 
urethra,  and  an  outward  flow  from  the  lower  angle  of  the  ex- 
ternal urethral  orifice  be  established.  Occasionally  the  orifice 
is  to  be  held  fast,  so  that  the  entire  anterior  urethra  is  dilated. 
This  should  be  done  twice  a  day  with  these  silver  salts  until 
the  discharge  decreases  and  becomes  thinner  and  more  muco- 
purulent in  character.  Permanganate  of  potassium,  once  a 
day,  at  first  1  :  3000,  and  in  the  course  of  a  few  days  1 :  1000, 
is  to  be  used.  Later,  weak  1  :  10,000  bichloride  of  mercury 
and  1  :1000  zinc  sulphate  solutions  are  to  be  advised.  These 
every  second  or  third  day,  depending  on  how  the  case  pro- 
gresses. The  treatment  may  extend  over  a  period  of  three 
to  six  weeks. 

Irrigations  carried  out  in  a  different  manner  are  advised : 
A  catheter  is  introduced  into  the  urethra  up  to  the  posterior 
end  of  the  anterior  urethra  and  connected  with  a  syringe  of 
100  to  150  c.c.  capacity  ;  the  solutions  used  are  the  same  as  in 
the  preceding  method.  The  advocates  believe  that  the  force 
with  which  the  fluid  is  injected  can  be  graduated  better. 

Combined  Methods. — It  is  scarcely  necessary  to  state 
that  combinations  of  all  the  local  methods  can  be  made,  and  it 
is  in  these  cases  that  the  best  results  are  obtained. 

Salves  and  Bougies. — Injections  of  salves  and  the  in- 
troduction of  medicated  bougies  are  also  used,  but  if  so,  are 
probably  more  adaptable  in  the  subacute  stages.  This  holds 
true  with  the  urethroscopic  treatment. 

Acute  Posterior  Urethritis. 

General  Features. — Usually  about  the  third  week,  sometimes 
before,  or  perhaps  after  that  time,  what  might  be  called  the 
turning-point  in  the  attack  is  reached.  It  usually  occurs 
when  the  gonorrhoea  is  at  its  height,  the  acme  generally  being 
the  third  week,  though  sometimes  earlier  or  later.    The  disease 


ACUTE  POSTERIOR    URETHRITIS.  113 

then  commences  to  improve  noticeably  and  all  the  inflamma- 
tory symptoms  to  subside,  or  the  process  shows  some  other 
signs  or  symptoms  that  were  not  present  previously — that  is, 
some  complication  has  arisen.  Usually  it  means  that  the 
gonorrhoea!  inflammation  has  passed  backward  into  the  poste- 
rior urethra,  and  if  it  does  so,  the  inflammation  extend.s 
upward  into  the  internal  urethral  orifice,  extending  then  from 
the  external  to  the  internal  orifice — that  is,  the  entire  length 
of  the  urethra.  This  turning-point  must  always  be  antici- 
pated, and  it  must  be  regarded  as  a  complication.  When- 
ever this  condition  occurs  there  is  no  question  but  that  it 
causes  grave  trouble  and  really  is  a  serious  condition.  Some- 
limes,  especially  if  the  symptoms  are  acute,  it  is  best  to  stop 
all  local  treatment  until  symptoms  abate. 

Etiology. — What  are  the  causes  of  a  posterior  urethritis? 
These  may  be  divided  into  practically  two  heads — viz.:  1. 
Internal,     2.  External. 

1.  In  the  internal  cases,  as  in  individuals  suffering  from 
other  diseases,  as  from  cachexia  on  account  of  tuberculosis, 
syphilis,  etc.,  it  is  a  creeping,  slow  process,  with  scarcely  any 
appreciable  symptoms. 

2.  In  the  external  cases  the  causes  are  sexual  excitement, 
an  increased  congestion,  the  inflammation  easily  passing  back- 
ward ;  injections ;  all  mechanical  manipulations,  etc. 

In  those  cases  where  these  inward  conditions  are  taken  into 
consideration  the  posterior  urethritis  is  of  a  creeping  character 
and  there  are  practically  no  symptoms  at  all.  Those  of  the 
outward  form  are  usually  of  a  peculiar  fulminating  form  of  a 
very  grave  type.  Where  this  posterior  urethritis  is  of  this 
creeping  nature  the  only  way  to  make  the  diagnosis  is  with 
the  Jadassohn  method  and  the  two-glass  method,  which  have 
been  described  elsewhere. 

As  just  said,  the  posterior  urethritis  manifests  itself  in  two 
different  ways — namely,  the  inward  and  the  outward  forms, 
as  follows  : 

Fii-st,  and  less  frequently  than  the  second  form,  it  is  un^ 
noticeable,  with  absolutely  no  symptoms  whatever.  The 
patient  does  not  urinate  frequently.     His  urinary  symptoms 

S— V.  D. 


114 


ACUTE  POSTERIOR    URETHRITIS. 


Fig.  4. 


are  no  different  than  those  in  a  simple  anterior  gonorrhoea. 
The  only  way,  then,  is  to  make  an  accurate  diagnosis  by  the 
two  methods  mentioned  before. 

Second,  and  most  common  form,  and  more  readily  recog- 
nized, is  usually  present  about  the  third  week,  with  chilly 
feeling,  sweats,  dull  pains  over  the  pubes  and  sometimes 
down  in  the  perineum,  frequent  urination  day  and  night,  per- 
haps tenesmus,  marked  pain, 
usually  when  the  urine  comes, 
sometimes  so  severe  that  the 
patient  hesitates  to  urinate. 
These  urinary  symptoms  are 
marked  both  day  and  night, 
though  perhaps  less  at  night 
than  during  the  day.  Urina- 
tion may  occur  every  fifteen 
to  thirty  minutes,  with  terri- 
ble agony.  The  sufferer  has 
to  go  to  bed,  but  gets  no 
sleep.  On  urination  at  the 
height  of  the  inflammation 
blood  appears  in  variable 
amount.  The  psychical  con- 
ditions at  this  time  are  not 
uncommon. 

Treatment.  —  First  Variety. 
— If  the  patient  has  been 
treated  locally  and  the  diag- 
nosis of  a  posterior  urethri- 
tis of  the  first  variety  has 
been  made,  where  the  symp- 
toms are  practically  absent, 
then  the  irrigation  can  be  continued,  but  the  fluid  should 
be  made  to  pass  into  the  bladder.  In  these  cases  the  irri- 
gator is  elevated  to  five  or  even  six  feet,  using  the  same 
solutions,  and  the  patient  instructed  to  keep  the  perineum 
lax,  or  as  if  going  through  the  act  of  urination.  After 
allowing   300  to   500  c.c.  to  pass  into  the  bladder  without 


Arzberger's  cooling  apparatus. 


ACUTE  POSTERIOR    URETHRITIS.  115 

causing  pain,  the  patient  should  then  evacuate  it  voluntarily. 
This  may  be  repeated  several  times  every  twenty-four  hours. 

If  not  successful  with  this  method,  then  the  Diday  method 
is  to  be  advised :  First,  wash  out  the  anterior  urethra ;  after 
this  introduce  a  small-caliber  catheter  into  the  posterior 
urethra.  Inject  about  200  c.c,  and  as  the  internal  sphincter 
is  weakest,  the  fluid  passes  into  the  bladder.  Introduce  the 
catheter  still  further  until  the  eye  of  the  catheter  is  in  the 
bladder ;  then  draw  oflp  the  fluid  ;  in  the  previous  step  the 
eye  of  the  catheter  is  between  the  internal  urethral  orifice  and 
the  bulbo-membranous  junction.  Then  repeat  the  procedure, 
and  finally  let  the  patient  pass  voluntarily  the  last  quantity 
injected. 

Second  Variety. — Whenever  the  symptoms  become  marked 
in  this  so-called  second  variety,  then  it  is  absolutely  neces- 
sary to  care  for  the  hygiene,  the  rest,  the  diet,  the  avoidance 
of  all  sexual  excitement,  or  the  condition  becomes  worse. 
Practically,  though,  before  this  point  is  reached,  the  prophy- 
lactic treatment  should  have  been  commenced,  as  it  may  pre- 
vent erections  and  pollutions,  and  in  this  manner  hinder  the 
posterior  trouble  from  setting  in. 

The  following  formulae  are  valuable  for  internal  adminis- 
tration to  allay  irritation  : 

I^     Lupulini, 

Camph.  monobrom.,     aa  5.0  grammes. 
M.  et  div.  in  cap.  No.  xv. 
Sig. — Two  or  three  at  night. 

I^     Potassii  bromidi,  30.0  grammes  ; 

Aquse  camphorse,  240.0        " 

M.    Sig. — One  tablespoonful  at  10  and  another  at 

11  p.  M. 

^     Lupulini,  3.0  grammes ; 

Morphinse  sulphatis,  0.1  gramme. 

M.  et  div.  in  cap.  No.  xv. 
Sig;. — One  or  two  at  niffht. 


116  ACUTE  POSTERIOR    URETHRITIS. 

Sometimes  if  the  patient  seizes  and  vigorously  squeezes  the 
inner  aspect  of  each  thigh  over  the  area  supplied  by  the  crural 
branch  of  the  genitocrural  nerve,  a  centripetal  inhibitory 
impulse  is  awakened  of  strength  sufficient  to  check  the 
erections  (Starr). 

After  the  onset  of  active  symptoms,  continue  giving  sandal- 
wood oil,  and  if  irrigations  have  been  given,  these  should 
be  inhibited,  especially  if  the  symptoms  are  acute;  in  fact, 
stop  local  treatment  of  all  kinds,  except  if  the  gonococcus  is 
present,  when  the  patient  may  use  a  non-irritating  injection, 
such  as  protargol,  which  does  not  heighten  the  inflammation 
if  used  in  moderate  strength. 

As  soon  as  the  symptoms  commence  to  subside,  the  local 
treatment  should  be  resumed.  Usually,  when  a  posterior 
urethritis  is  present,  it  is  evidence  that  the  gonococcus  is  still 
present.  If  so,  gonorrhoeal  treatment  must  again  be  resorted 
to,  irrigating  directly  into  the  bladder,  as  outlined  in  one  of 
the  foregoing  methods. 

Suppositories  are  soothing,  giving  rest  to  the  parts  and 
acting  as  antiphlogistics. 

^i     Ext,  belladonnse,  0.25  gramme ; 

Ichthyolis,  2.50  grammes ; 

Butyrae  cocse,          q.  s. 


M. 

Fiaut  in  suppos.  No.  x. 

Sig. 

— Insert  one  morning  and  night. 

^ 

Ext.  belladtmnse, 

Ext.  opii,                        aa  0.25  gramme; 

Ichthyolis, 

Iodoform i,                      aa  2.50  grammes ; 

Butyrse  cocse,     q.  s. 

M. 

Fiant  in  suppos.  rect.  No.  x. 

Sig. 

, — Insert  one  night  and  morning. 

^ 

lodoformis,                           1.0  gramme; 

Butyrse  cocee,     q.  s. 
M.    Fiant  in  suppos.  rect.  No.  x. 
Siii'. — Insert  two  or  three  each  day 


CHRONIC  ANTERIOR    URETHRITIS.  117 

In  addition,  tlie  Arzberger  cooling  apparatus,  which  is  in- 
troduced into  the  rectum,  may  be  used.  Fasten  this  to  an 
ordinary  rubber  irrigator,  and  allow  cold  water  to  run  in  and 
out  four  or  five  times  in  twenty-four  hours  for  fifteen  minutes 
each  time. 

Chronic  Anterior  Urethritis. 

Etiology. — Whenever  this  condition  remains  after  an  acute 
attack,  it  is  most  commonly  due  to  neglect  or  even  ill  treat- 
ment, although  there  are  cases  that  are  prolonged  even  in 
spite  of  careful  treatment. 

Symptoms. — Any  portion  of  the  urethra  may  become  in- 
volved. The  changes  are  principally  in  the  color  and  trans- 
parency of  the  mucous  membrane,  epithelial  metaplasia, 
lesions  in  and  about  the  follicles,  and  more  or  less  cicatriza- 
tion of  all  the  chronic  processes.  Frequently  granulations 
occur,  and  these  are  the  beginning  of  strictures.  Whenever 
the  posterior  urethra  becomes  involved  in  a  chronic  process, 
the  prostate  gland  or  seminal  vesicles  or  both  are  almost  posi- 
tively involved.  However,  in  order  to  make  a  clinical  classi- 
fication. Finger  classifies  all  cases  as  follows: 
.  1.  Circumscribed  areas  involved,  and,  in  addition,  the 
entire  urethra  still  shows  slight  signs  of  congestion. 

2.  Where  the  process  is  still  recent,  but  where  it  is  invet- 
erate,— i.  e.,  localized  in  one  spot, — without  any  accompanying 
congestion. 

In  a  chronic  urethritis  there  is  usually  a  continuous  dis- 
cliarge  ;  often  but  a  ""  gluing "  of  the  external  urethral  ori- 
fice, usually  only  in  the  morning,  on  arising,  on  account  of  the 
long  interval  between  urinations.  There  may  be  a  distinct 
discharge.  If  sufficient  to  form  a  drop,  it  is  referred  to  as 
a  "  goutte  militaire."  Most  often  there  is  no  accompanying 
pain  or  discomfort,  although  when  the  stream  starts,  there 
may  be  a  sticking  or  sharp  cutting  pain,  or  but  a  slight  burn- 
ing sensation  during  the  time  of  urination.  On  urinating 
into  two  glasses,  the  first  will  contain  all  the  secretion,  while 
the  second  will  contain  the  clear  urine ;  or  if  the  anterior 
urethra  is  thoroughly  irrigated,  the  entire  quantity  of  urine 


118  CHRONIC  POSTERIOR    URETHRITIS. 

voided  should  be  clear.  To  establish  the  diagnosis  more  pos- 
itively, introduce  a  diagnostic  sound  to  the  membranous  ure- 
thra, then  massage  the  urethra  from  the  outside  as  the  sound 
is  withdrawn.  In  this  manner  the  glands  and  crypts  will  be 
made  to  empty ;  furthermore,  any  infiltrations  are  readily 
felt.  The  discharge  thus  obtained  should  be  examined  micro- 
scopically. The  urethroscopic  examination  in  these  cases 
should  not  be  omitted.  In  this  type  the  glandular  openings 
are  patent,  folds  of  the  mucous  membrane  absent,  lessened 
gloss,  a  dark-red  hue,  or  more  or  less  involvement  of  the 
epithelial  layer,  as  already  described. 

Clironic  Posterior  Urethritis. 

Symptoms. — This  affection  usually  accompanies  a  chronic 
inflammatory  condition  of  the  anterior  urethra,  although  it 
occasionally  is  found  to  occur  independently.  Authorities 
differ  as  to  whether  this  condition  must  always  be  accom- 
panied by  a  prostatitis.  On  account  of  the  absence  of 
Littre's  glands  and  of  crypts  in  the  membranous  urethra, 
this  last  is  not  so  markedly  involved  as  the  prostatic  urethra, 
where  the  opening  of  the  prostatic  ducts,  ejaculatory  ducts, 
and  the  utriculus  masculinus  are  found.  If  the  anterior  ure- 
thra is  involved,  the  inflammatory  process  may  extend  into 
the  posterior  urethra.  In  all  these  cases  a  discharge  may  or 
may  not  be  present,  and  is  often  intermittent  and  occasionally 
noticed  only  at  the  time  of  defecation  or  on  straining.  To 
differentiate  it  from  a  strictly  anterior  urethritis,  there  is  often 
an  increased  frequency  of  urination ;  besides,  the  desire  to 
urinate  arises,  which  the  patient  cannot  readily  withstand. 
As  in  other  posterior  affections,  the  sensations  of  slight  burn- 
ing or  pain  may  be  referred  to  the  glans  penis.  Nothing- 
abnormal  is  to  be  felt  on  rectal  examination.  Diagnostic 
sounds  may  reveal  an  especially  sensitive  posterior  urethra  ; 
the  urethroscope,  a  congested,  easily  bleeding,  irregularly 
folding  mucous  membrane,  and  the  bladder  opening  shows 
signs  of  involvement.  By  irrigating  the  anterior  urethra 
until  free  from  specks  and  then  allowing  patient  to  urinate 


CHRONIC  POSTERIOR    URETHRITIS.  119 

into  two  glasses,  the  first  would  be  turbid  or  contain  fila- 
ments, and  the  second  would  be  clear  if  the  interval  of 
urination  were  short  and  the  amount  of  secretion  small  ;  if 
the  amount  of  secretion  were  large,  the  contents  of  the  second 
glass  would  also  be  turbid,  as  the  quantity  in  excess  of  the 
capacity  of  the  posterior  urethra  would  flow  into  the  bladder. 
Treatment. — Naturally  the  treatment  of  these  chronic  cases 
depends  upon  whether  the  anterior  or  the  posterior  ure- 
thra or  both  are  involved,  or  whether  or  not  the  lesion  is 
accompanied  by  complications ;  also  as  to  whether  the  con- 
dition is  but  recent  or  of  long  standing  ;  whether  or  not  aggra- 
vated by  prolonged  treatment ;  whether  or  not  the  gonococcus 
is  present ;  and,  finally,  whether  or  not  the  patient  is  aifected 
by  any  constitutional  disease.  It  is  readily  understood  how 
these  conditions  may  affect  the  treatment.  For  instance,  if 
treatment  has  been  very  prolonged,  especially  if  local,  it  must 
be  discontinued ;  if  the  gonococcus  is  present,  the  local  treat- 
ment must  be  directed  against  this  germ.  If  the  patient  is 
cachectic,  the  condition  causing  it  must  be  taken  into  con- 
sideration. However,  in  all  cases  the  treatment  usually  con- 
sists of  both  internal  and  local  medication.  The  internal 
treatment,  with  reference  to  Avhether  or  not  it  is  recent  or  of 
long  duration,  should  be  as  outlined  in  the  preceding  pages. 
Where  the  posterior  urethra  is  involved,  internal  remedies 
should  never  be  neglected,  especially  when  symptoms  which 
arise  from  this  region  are  present.  In  almost  all  cases  the 
local  treatment  is  the  most  important.  In  all  cases  the 
symptoms  and  the  urine  are  indications  for  the  treatment. 
If  the  anterior  urethra  only  is  involved,  the  local  treatment 
should  extend  over  this  part  only.  If  the  area  involved  is 
circumscribed,  but  the  entire  urethra  is  congested,  the  urine 
usually  shows  considerable  mucus  in  the  first  glass,  and  may 
be  slightly  turbid.  In  these,  daily  irrigation  of  perman- 
ganate of  potassium  1  :  3000  to  1  :  1000,  and  later  followed 
with  a  mixture  of  1  :  10,000  bichloride  of  mercury  and 
1  :  1000  sulphate  of  zinc  solutions  may  be  of  great  service. 
When  the  process  is  more  localized,  with  no  congestion  of 
tiie  urethra,  the  contents  of  the  first  glass  show  distinct  fila- 


120 


CHRONIC  POSTERIOR    URETHRITIS. 


ments  and  absence  of  tnrbidity.     In  these  cases,  when  com- 
YiQ,  5.  plications  are  absent,  sounds  shonld  be 

passed  as  large  as  the  urethral  orifice 
will  permit.  If  necessary,  the  orifice 
must  be  enlarged.  To  reach  all  the 
parts  of  the  anterior  urethra,  the  sound 
must  be  introduced  into  the  posterior 
urethra.  This  also  holds  true  when  ir- 
rigating— i.  e.,  the  irrigating  fluid  in 
the  chronic  cases  must  reach  the  pos- 
terior urethra.  In  all  these  cases,  tchen- 
ever  sounds  are  passed,  the  injiltrcdions 
should  he  thoroughly  massaged  over  the 
sound.  The  sounds  to  be  used  in  these 
cases  are  those  called  Benique's.  As 
already  described,  they  have  the  nor- 
mal curvatures  of  the  urethra,  and  are 
usually  cylindrical,  Avith  very  blunt  tip. 
If  the  gonococcus  is  present,  the  treat- 
ment remains  as  already  outlined.  In 
all  cases  of  urethral  disease  where  com- 
plications are  absent,  it  can  almost  posi- 
tively be  stated  that  the  following  is  a 
fairly  accurate  guide  and  may  be  ad- 
hered to  :  If  the  urine  is  turbid,  if  due 
to  pus,  and  if  local  treatment  is  indi- 
cated, the  more  turbid  the  urine,  the 
weaker  the  irrigation  ;  and  the  less  tur- 
bid, the  stronger  the  irrigation.  If  fila- 
ments are  long  and  light,  comparatively 
iveak  instillations ;  the  shorter  and 
heavier,  the  stronger  the  instillations 
demanded. 

AVith  the  methods  outlined  it  is 
readily  ascertainable  whether  both 
the  anterior  and  posterior  urethra  are 

Guyon's  sTrinse  and  capped     involved.     The    treatment    should    be 
hMtion.!'"''"'""'''"''''     governed   by   the  parts  involved  and 


CHRONIC  POSTERIOR    URETHRITIS.  121 

also  by  the  presence  or  absence  of  the  gonococcus,  and  in 
general  should  be  carried  out  according  to  the  above  outline. 
/Soluble  bougies  and  cupped  sounds  for  the  appliccdion  of  salves 
are  rarely  used,  because  they  are  veritable  foreign  bodies,  and 
hence  are  apt  to  irritate.  The  treatment,  therefore,  consists 
practically  of  irrigation,  instillations,  passing  of  sounds,  and 

Fig.  6. 


Keyes's  deep  urethral  syringe. 

topical  applications  through  the  urethroscope.  Whenever 
threads  are  short  and  heavy  and  there  is  absence  of  turbidity 
to  the  urine,  and  if  they  arise  in  both  anterior  and  posterior 
urethra,  instillations  with  the  Keyes  or  Ultzmann  capillary 
catheter  are  made — usually  every  second  day,  commencing 
with  a  0.25  per  cent,  nitrate  of  silver  solution  and  gradually 
increasing  to  2  or  3  per  cent,  or  ever  higher  if  indicated. 
Besides,  sounds  should  be  passed.  In  order  to  avoid  en- 
larging the  external  urethral  orifice  by  incision,  dilatations 
of  various  description,  and  some  used  for  irrigating  at  the 
same  time,  can  be  used.  Metal  sounds  are  the  least  painful 
and  most  easily  sterilized  instruments,  and  certainly,  when- 
ever possible,  should  be  used  in  preference  to  dilators.  Local 
applications  of  whatever  character,  direct  applications  of  sol- 
utions, electrolysis,  or  galvanocautery,  can  be  used  with  the 
aid  of  the  urethroscope.  They  may  be  used  in  the  posterior 
urethra  as  easily  as  in  the  anterior.  In  all  cases  of  chronic 
affections  the  urethroscope  can,  at  least  for  diagnostic  pur- 
poses, be  used  to  advantage.  In  this  way  the  involvement 
of  the  urethral  glands  or  granulating  surfaces  may  be  diag- 
nosed. If  the  treatment  is  carried  out  through  the  tubes  for 
any  length  of  time,  unnecessary  traumatism  may  occasionally 


122  URETHRITIS  IN  FEMALES. 

be  caused,  whereas  if  an  irrigation  treatment  had  been  insti- 
tuted, good  and  quick  results  could  have  been  attained. 

Nitrate  of  silver  has  a  distinct  bactericidal  action.  It  is, 
however,  irritating,  especially  in  the  posterior  urethra.  It  is 
a  mild  caustic  in  the  strengths  used ;  and  it  has,  besides,  a 
slightly  astringent  quality. 

Protargol  may  be  used  for  instillations  whenever  the  gono- 
coccus  is  present,  and  in  all  cases,  if  desirable,  can  be  applied 
in  strength  varying  from  1  to  25  per  cent,  solutions,  and  is 
much  less  irritating  than  the  nitrate  of  silver,  is  penetrating, 
and  is  a  bactericide. 

Ichthyol  in  instillations,  in  1  to  5  per  cent,  strength,  where 
antiphlogistic  action  is  desired,  where  the  mucous  membrane 
is  congested,  and  where  there  is  burning  at  the  time  of  urina- 
tion, has  a  distinct  soothing  effect.  Here  nitrate  of  silver 
would  cause  considerable  pain  at  the  time  of  application. 

Copper  sulphate  solutions,  from  5  to  25  per  cent,  in  strength, 
are  used  ;  these  are  especially  valuable  as  an  astringent  and 
in  catarrhal  conditions  of  the  posterior  urethra. 

Sulphate  of  thallin  is  used  in  solution  in  strengths  varying 
from  2  to  10  per  cent.,  especially  where  an  astringent  and  but 
slight  bactericidal  action  is  desired. 

All  these  are  used  in  quantities  of  1  or  2  c.c,  and  applied 
by  the  aid  of  a  capillary  catheter,  either  of  flexible  material 
with  olive  tip  (then  called  a  Guyon  capillary  catheter),  or  a 
metal  capillary  catheter  with  a  very  short  beak  (the  Ultzmann 
capillary  catheter).  Such  are  especially  indicated  in  chronic 
affections,  although  irrigations  are  often  desirable  and  neces- 
sary adjuvants  to  the  treatment. 

Whenever  gonorrhoea  occurs  in  young  boys  it  is  best  to  rely 
mostly  on  the  hygienic  and  internal  treatment,  as  it  is  most 
difficult  to  treat  locally.  As  soon  as  the  patient  understands 
and  can  carry  out  the  local  treatment,  it  is  to  be  instituted. 

Urethritis  in  Females. 

A  brief  outline  is  desirable.  Again  the  gonococcus  is  the 
most  frequent  cause  of  infection.     The  period  of  incubation  is 


STRICTURE   OF  THE    URETHRA.  123 

possibly  shorter  than  in  men — about  two  to  three  days.  The 
production  of  pus  is  copious  at  first,  but  the  amount  rapidly 
lessens  in  the  urethra.  The  symptoms  may  almost  l)e  un- 
noticeable,  and  again  the  desire  to  urinate  may  be  very  fre- 
quent and  each  act  highly  painful,  and  palpation  shows  the 
urethra  to  be  sensitive,  and  the  external  urethral  orifice  presents 
inflammatory  signs.  This  stage  readily  passes  into  the  sub- 
acute and  then  into  the  chronic  stage.  The  laminse  and  crypts 
about  the  urethral  orifice  always  show  involvement  in  the 
chronic  cases.  The  diagnosis  is  readily  made  from  what  has 
already  been  mentioned  under  urethritis  of  the  male.  The 
treatment  is  certainly  of  just  as  much  importance  as  it  is  in 
the  male.  In  the  acute  cases  it  is  best  to  refrain  from  all 
local  treatment,  give  rest  in  bed,  antiseptic  applications  to 
the  genitalia,  and  internal  treatment  prescribed  as  indicated. 
Most  cases,  however,  pass  into  the  chronic  condition.  In 
these  cases  instillation  of  the  silver  salts  whenever  the  gono- 
coccus  is  present,  and  when  absent,  iodoform  bougies,  and 
later  suppositories  containing  astringents.  Urethroscopic  ex- 
aminations and  treatment  often  become  necessary.  Crypts 
are  to  be  treated  directly  with  applications.  Strictures  are 
rarely  met.  If  present,  dilatation  as  in  the  male  is  carried 
out. 

Stricture  of  the  Urethra. 

A  stricture  is  a  narrowing  or  a  loss  in  the  dilatability  of 
the  urethral  canal  produced  by  changes  in  its  walls.  These 
changes  may  be  due  either  to  transformation  of  tissue,  and 
then  they  are  permanent;  or  transient,  and  caused  by  mus- 
cular contraction.  The  latter  are  called  spasmodic  strictures, 
and  appear  mostly  in  neurotic  individuals. 

Spasmodic  Strictures. 

The  immediate  cause  for  their  appearance  is  any  local  irri- 
tation caused  either  by  a  foreign  body  or  reflexly  from  the 
rectum,  hyperacidity  of  the  urine,  etc.  These  spasmodic 
strictures  usually  occur  in  the  membranous  urethra,  through 
the  contractions  of  the  unstriped  muscular  fibres  surrounding 


124  STRICTURE   OF  THE   URETHRA. 

the  urethra.  Such  strictures  always  occur  suddenly,  no  im- 
pairment of  the  passage  having  previously  been  noticed.  It 
disappears  just  as  quickly,  especially  if  gentle  pressure  is 
brought  into  action  by  a  heavy  sound.  In  cases  of  reflex 
spasms  a  hot  bath,  a  hot  poultice,  or  in  extreme  cases  a  hypo- 
dermic injection  of  0.01  gramme  of  morphine  will  bring 
about  prompt  relief. 

Organic  Strictures. 

Strictures  due  to  permanent  changes  in  the  urethral  walls, 
or  the  so-called  organic  strictwes,  a.re  the  result  of  the  organi- 
zation of  inflammatory  infiltrations  of  the  urethral  mucosa  or 
the  submucous  layers. 

Symptoms. — Organic  strictures  may  occur  in  different 
forms.  They  may  be  very  superficially  located,  and  then 
either  appear  as  small  strands  imljedded  in  the  mucosa  or 
may  protrude  into  the  urethra  as  suiall  folds  of  various 
dimensions.  They  run  in  either  an  oblique  or  a  transverse 
direction,  and  with  the  aid  of  the  urethroscope  appear  as 
whitish,  shining  stripes,  or  consist  of  cicatricial  tissue  which 
passes  down  into  the  submucous  layers,  which  gives  a  some- 
what similar  appearance.  By  a  permanent  concentric  contrac- 
tion of  this  tissue  the  urethral  canal  becomes  more  and  more 
narrowed.  Although  these  cicatrices  surround  the  urethra 
as  a  rule  only  partially,  in  rare  instances  even  a  complete 
rigid  ring  may  be  formed.  The  strictures  are  seated  chiefly 
on  the  lower  floor  of  the  urethra.  As  already  mentioned,  the 
strictures  are  the  end-product  of  inflammatory  infiltrations  in 
the  mucosa,  preferably  around  the  glands  aud  crypts. 

In  the  further  course  these  infiltrations  become  organized 
to  connective  tissue  which  shrinks.  If  this  takes  place  on 
the  surface,  only  eccentric  shrinkage  is  the  result,  and 
there  will  be  no  impairment  of  the  canal,  wdiile  deep-seated 
cicatrization  by  concentric  shrinkage  obstructs  the  canal. 
Most  organic  strictures  are  due  to  gonorrhoeal  inflammation  ; 
but  traumatism  of  the  urethra,  if  resulting  in  infiltration  and 
cicatrization,  may  produce  strictures.     In   rare  instances  we 


STRICTURE  OF  TEE   URETHRA.  125 

find  congenital  strictures,  which,  as  a  rule,  present  themselves 
in  the  membranous  urethra  as  very  small  elastic  bands,  or  in 
the  prostatic  urethra  as  encircling  fibres  (Fuller).  The  num- 
ber of  strictures  in  individual  cases  depends  entirely  upon  the 
number  of  the  previous  infiltrations,  so  that  we  may  encounter 
one  or  any  number  of  strictures  in  the  same  urethra.  The 
most  common  seats  of  strictures  are  the  bulbo-membranous  junc- 
tion and  the  fossa  navicularis. 

It  is  best  to  distinguish  between  soft  strictures  which  are 
produced  by  soft  inflammatory  cellular  infiltration,  which 
easily  gives  way  to  the  intruding  sound  ;  hard  strictures, 
where  there  are  distinct  fibrous  changes,  aud  where  the  dila- 
tabilitv  is  verv  slisfht  ;  and  elastic  strictures,  which  althouo^h 
readilv  givino-  wav  to  the  intruding  sound  of  the  lars^er  size, 
return  to  their  former  caliber  immediately  upon  withdrawal 
of  the  instrument.  The  symptoms  which  are  produced  by 
strictures  are,  so  far  as  the  patient's  observations  are  con- 
cerned, increase  of  the  desire  for  urinating,  burning  sensa- 
tions during  micturition,  and  eventually  painful  sensations 
in  the  affected  areas  during  intercourse.  The  objective 
symptoms  are,  first,  the  involvement  of  the  urinarv  stream. 
It  is  either  twisted  or  split  up  into  two  or  three  parts,  and 
has  lost  a  more  or  less  considerable  part  of  its  force.  Often 
the  patient  has  to  wait  a  long  time  for  the  appearance  of  the 
full  stream,  or  must  obtain  the  co-operation  of  the  abdominal 
muscles  in  order  to  start  the  urinary  flow  and  to  emptv 
the  bladder.  In  severe  cases  the  urine  is  squeezed  out  in 
drops  ;  consequently  it  takes  a  very  long  time  to  empty  the 
bladder.  By  this  constantly  increased  demand  on  the  expul- 
sive power  of  the  bladder  its  muscular  coat  hypertrophies, 
which  manifests  itself  by  a  thickening  of  the  bladder-walls 
and  the  protruding  into  the  viscus  of  the  so-called  trabecule^. 
These  are  nothing  more  than  hypertrophied  bundles  of  mus- 
cular fibres.  The  presence  of  stricture  always  maintains  the 
existence  of  a  catarrh  of  the  urethral  mucosa.  Posteriorlv  to 
the  stricture  a.  dilatation  of  more  or  less  extent  usually  tahes 
place.  This  gives  rise  to  the  appearance  of  the  phenomenon  of 
"  dribbling.'^     Part  of  the    urine  alwavs   accumulates    after 


126  STRICTURE  OF  THE   URETHRA. 

micturition  behind  the  stricture,  and  after  the  bladder  is 
emptied,  this  retained  urine  dribbles  out  of  the  urethra.  If 
the  stricture  becomes  very  tight,  sterility  may  be  the  conse- 
quence. The  ejaculated  semen  is  retained  by  the  stricture, 
regurgitates  into  the  bladder,  and  is  afterward  emitted  with 
the  urine. 

Once  in  a  while  a  stricture  suddenly  becomes  impervious 
if  it  becomes  inflamed  by  rough  or  unclean  instrumentation, 
or  if  a  sudden  congestion  is  provoked  by  debaucheries  of  the 
patient.  Then  absolute  retention  of  the  urine  takes  place, 
which,  if  it  is  impossible  to  pass  a  catheter,  may  be  relieved 
by  puncture  of  the  bladder,  which  is  best  performed  by 
using  a  trocar  or  a  capillary  needle  and  an  aspirator,  or  by 
urethrotomy.  Inflammation  of  the  stricturing  tissue  itself, 
or  of  the  adjacent  tissue,  results  in  some  cases  in  the  forma- 
tion of  abscesses  which  perforate  up  to  the  surface  of  the 
penis,  so  that  fistulse  are  established,  which  lead  from  the 
urethral  canal  to  the  surface.  Such  fistulse  may  appear  any- 
where in  the  neighborhood  of  the  urethra.  In  rare  cases  per- 
ineal fistulse  resulting  from  large  urinary  abscesses  communi- 
cate with  each  other.  If  these  suppurating  centres  perforate 
into  the  urethra  only  without  reaching  the  outside  surface, 
the  urine  becomes  accumulated  in  these  cavities  and  extra va- 
sates  into  the  tissues,  producing  necrosis  and  reactive  suppura- 
tion. This  condition  is  known  as  urinary  infiltration,  and  if 
free  drainage  by  extensive  incisions  is  not  very  soon  estab- 
lished, death  results  from  sespsis. 

Diagnosis. — The  proper  method  of  diagnosing  stricture  is 
by  the  exploration  of  the  urethra  by  means  of  an  olive-tipped 
sound.  The  usual  method  of  attempting  to  pass  equally 
calibred  sounds  gives  unsatisfactory  results.  If  we  use  an 
olive-tipped  sound,  we  enter  a  stricture  quite  easily  and  pass 
it  easily,  but  in  withdrawing  the  olive  is  caught  at  its  posterior 
circumference  and  remains  "  engaged "  until  the  stricture  is 
passed,  so  that  we  get  a  fair  estimate  as  to  the  calibre  of  the 
stricture  as  well  as  to  its  length.  Furthermore,  if  a  num- 
ber of  strictures  exist  in  the  same  urethra,  it  is  impossible  to 
diagnose  all  the  strictures  by  means  of  the  uniformly  call- 


STRICTURE   OF  THE    URETHRA.  127 

bred  sound.  An  olive-tipped  sound,  after  it  has  passed 
through  a  stricture,  is  easily  movable  and  free  because  of  the 
minimal  size  of  its  shaft,  and  the  olive  is  free  until  it  is  again 
caught  in  the  next  stricture.  This  shaft  of  the  sound  is  grad- 
uated so  that  it  is  possible  to  diagnose  accurately  the  depth 
in  the  canal  at  which  the  stricture  is  located.  The  examina- 
tion is  always  commenced  by  using  the  largest  olive  which 
possibly  can  be  passed  through  the  meatus.  If  this  should 
be  below  the  normal  size,  it  must  be  enlarged  by  an  incision 
which  runs  toward  the  fraenulum. 

Meatotomy. — This  operation  is  called  meatotomy.  When- 
ever made,  it  is  best  to  bring  together  the  mucous  mem- 
brane of  the  urethra  with  the  lower  angle  of  the  incision  on 
both  sides  with  two  or  three  fine  catgut  sutures.  If  this  is 
not  done,  in  order  to  prevent  union,  the  incised  part  must  be 
kept  apart  by  passing  sounds  daily.  Oftentimes  in  these 
cases  where  meatotomy  is  necessary,  an  exceedingly  short 
frsenulum  is  present.  It  is  desirable  to  lengthen  these.  This 
can  readily  be  accomplished  by  incising  the  frsenulum  at  right 
angles,  then  bringing  the  wound  together,  and  suturing  at 
right  angles  to  the  incision,  thus  increasing  the  length  of 
the  frsenulum  to  practically  the  length  of  the  incision. 

Another  method  of  measuring  the  calibre  of  strictures 
is  by  using  the  Otis  urethrometer.  This  consists  of  a  shaft 
having  at  its  lower  end  a  bulb  which  may  be  spread  out  and 
enlarged,  and  again  contracted  by  the  screw  at  its  handle. 
The  changes  in  the  bulb  are  shown  on  the  index.  Before  the 
instrument  is  introduced  into  the  urethra  the  bulb  is  covered 
with  a  rubber  cap  so  as  to  avoid  catching  of  folds  in  the 
mucous  membranes. 

The  examination  of  the  urethra  by  means  of  instruments 
must  always  be  done  under  aseptic  precautions.  The  in- 
struments must  be  sterilized  by  boiling,  and  the  hands  of  the 
operator  must  be  cleansed  and  disinfected  in  the  usual  way. 
The  meatus  must  be  washed  with  an  antiseptic  solution. 
Although  it  is  impossible  to  sterilize  the  urethral  canal  relia- 
bly, it  is  advisable  to  cleanse  it  as  far  as  possible,  either  by  a 
previous  irrigation  or  by  having  the  patient  urinate. 


128  STRICTURE   OF  THE    URETHRA. 

Treatment  of  Strictures. — Strictures  may  be  treated  either 
by  instrumental  dilatation  or  by  cutting  operations.  The 
choice  of  instruments  depends  upon  the  clinical  features  of  the 
stricture.  If  a  stricture  is  easily  entered,  steel  sounds  are  used. 
Strictures  which  are  located  in  the  anterior  urethra  are  dilated 
by  means  of  straight  short  sounds  (Dittel's  uretliral  rods).  If 
the  strictures  are  situated  in  the  posterior  urethra,  curved 
sounds  with  conical  tips  are  used.  At  the  beginning  the 
largest  sound  which  can  be  passed  without  difficulty  is  always 
used.  This  sound  is  allowed  to  remain  for  a  few  minutes, 
and  is  followed  at  the  next  sitting  by  the  next  larger  sound.  If 
the  patient  is  very  tolerant,  after  a  fev/  treatments  two  sounds 
may  be  used  at  one  sitting.  The  sounding  must  be  continued 
with  sounds  of  increasing  size  until  the  normal  calibre  and 
dilatability  of  the  urethra  are  restored.  If,  despite  meatotomy, 
the  meatus  should  not  allow  of  introducing  sounds  of  a  size 
sufficient  for  the  dilatation  of  the  posterior  urethra,  the  pre- 
viously mentioned  dilators,  with  or  without  irrigation  attach- 
ment, may  be  used  to  advantage.  In  case  it  should  be  im- 
possible to  enter  the  stricture  by  means  of  steel  sounds,  one 
of  the  following  methods  must  be  employed  : 

A  bundle  of  filiform  bougies  with  varying  shaped  tips  is 
inserted  into  the  urethra ;  then,  after  the  urethra  is  injected 
with  olive  oil  and  the  patient  asked  to  attempt  to  urinate,  the 
external  urethral  orifice  is  held  fast  and  one  bougie  after 
another  is  manipulated  so  as  to  cause  it  to  pass  the  constric- 
tion. One  of  them  very  probably  will  lie  opposite  the  entrance 
of  the  stricture  and  may  be  passed  through  it.  If  successful 
in  passing  such  a  bougie,  it  is  left  in  situ  and  secured  with 
adhesive  plaster  about  the  glans  and  left  in  place  for  one  or 
two  days.  The  patient  is  then  instructed  to  urinate  without 
withdrawing  it.  In  case  this  is  not  possible  it  must  be  re- 
moved. If  tolerated,  the  contact  of  the  foreign  body  sets  up 
an  inflammation  and  causes  a  softening  and  absorption  of  the 
stricture.  In  this  manner  a  larger  bougie  can  be  inserted  the 
following  day,  and  the  procedure  may,  if  necessary,  be  re- 
peated until  in  the  cr)urse  of  some  days  dilatation  can  be  pro- 
ceeded with  bv  means  of  the  metal  sounds.     Or  the  entrance 


STRICTURE  OF  THE   URETHRA.  129 

of  the  stricture  is  found  by  means  of  the  urethroscope,  and 
if  this  opening  is  fixed  in  the  field  of  view,  the  bougie 
is  made  to  enter  through  the  endoscopic  tube.  These  two 
methods  are  used  preferably  in  very  tight  strictures. 

Occasionally,  by  injecting  subcutaneously  twenty-four  hours 
previous  to  attempting  to  pass  bougies  in  these  severe  cases  of 
stricture^  0.1  c.c.  of  a  15  per  cent,  alcoholic  solution  of  thio- 
sinamin  hydrochlorate,  one  may  be  successful  where  he  would 
have  othertvise  failed. 

In  less  difficult  cases,  which  do  not  allow  of  passing  the 
steel  sounds  immediately,  elastic,  cone-shaped  bougies  are  to 
be  used.  They  quite  often  enter  and  pass  a  stricture  which 
is  impermeable  to  a  steel  sound.  In  order  to  follow  the 
passing  of  a  fine  bougie  immediately  by  the  introduction  of  a 
steel  sound,  an  instrument  called  the  Le  Fort  sound  and 
bougie  is  employed.  This  consists  of  a  very  fine  elastic 
bougie  which  carries  on  its  central  end  a  screw- worm,  so  that 
steel  sounds  of  different  sizes  may  be  attached.  If  this  bougie 
is  passed  through  a  stricture,  the  attached  steel  sound  is  easily 
introduced,  following  the  bougie  as  a  guide.  The  bougie 
itself  curls  up  in  the  bladder.  This  practically  consists  of 
forcible  dilatation,  and  is  not  to  be  recommended  except  in 
certain  cases.  Even  if  a  stricture  is  completely  dilated,  the 
sounding  must  be  kept  up  until  the  whole  urethra  is  rendered 
soft  and  elastic,  and  the  patient  is  to  be  advised  to  have  a  large 
sound  passed  at  stated  intervals ;  these  intervals  at  first  are 
short  and  then  longer,  in  order  to  prevent  shrinkage  of  the 
dilated  parts  :  an  average  rule  is  to  pass  a  sound  by  gradual 
stages  once  in  five,  seven,  fourteen,  thirty,  sixty  days,  then 
every  three,  four,  six  months.  Probably  every  stricture 
should  have  a  sound  passed  through  it  every  three  to  six 
months. 

In  some  cases  strictures  are  encountered  which  react  on 
each  attempt  of  sounding  by  inflammation  and  urethral  fever  ; 
or  strictures  which,  on  account  of  their  elasticity,  cannot  be 
cured  by  dilatation.  All  these  strictures  must  be  treated  by 
cutting  operations."  The  same  holds  true  for  strictures  which 
protrude  into  the   urethral  canal  as  valves,  flaps,^  or  bands, 

9— V.  D. 


130  STRICTURE  OF  THE   URETHRA. 

and  for  strictures  which  take  a  tortuous  course.  The  cutting 
operations  which  are  employed  for  dividing  strictures  are 
called  external  and  internal  urethrotomy. 

Internal  Urethrotomy. — This  is  performed  with  instruments 
of  varying  shape,  but  all  are  sound-shaped  and  carry  a  pro- 
tected knife.  This,  after  the  point  of  instrument  has  passed 
the  stricture,  is  uncovered  and  then  withdrawn,  cutting  the 


Otis'  urethrometer. 


stricture  as  it  passes  toward  the  meatus.  The  most  pop- 
ular instrument  for  this  purpose  is  the  Otis  dilating  ure- 
throtome. This  instrument  has  two  branches,  which  may 
be  spread  out  by  means  of  the  screw  at  its  handle,  and  thus 
fixes  the  instrument  tightly  against  the  stricture.  The  screw 
is  connected  with  an  indicator  running  over  a  graduated  disc, 
so  that  the  degree  of  distention  can  be  gauged  exactly.     After 

Fig.  8. 


Otis'  urethrotome. 

the  instrument  is  passed  through  the  stricture  and  the  desired 
dilatation  is  reached,  the  knife  which  is  hidden  in  the  upper 
branch  is  uncovered  and  slowly  withdrawn  until  the  stricturing 
fibres  are  divided  entirely.  Then  the  instrument  is  screwed 
together  again  and  withdrawn.  The  hemorrhage,  as  a  rule, 
is  very  slight,  and  can,  in  case  of  necessity,  be  checked  by 
hot  irrigations.     In   severe  cases  a  metal  catheter  is  intro- 


STRICTURE  OF  THE   URETHRA.  131 

duced  up  into  the  bladder  and  the  penis  bandaged  over  it, 
so  that  the  bleeding  is  arrested  by  compression.  It  is  a  good 
])lan  always  to  introduce  a  small  iodoform  wick  into  the  ure- 
thra after  internal  urethrotomy.  This  may  remain  there  until 
the  next  micturition.  Internal  urethrotomy  should  be  j^radised 
only  in  the  pendulous  part  of  the  urethra. 

Preparatory  to  all  procedures  on  the  urethra  uriuary  anti- 
septics should  be  given,  such  as — 

^     Urotropini, 

Salol,  aa  5.0  grammes. 

Div.  in  caps.  No.  xv. 
Sig. — One  capsule  with  water  every  four  hours. 

In  performing  internal  urethrotomy  it  is  advisable,  just 
previous  to  any  operative  step,  to  irrigate  the  anterior  ure- 
thra with  a  warm  saturated  boric  acid  solution.  After  the 
cutting  the  penis  should  be  protected  with  a  hot  fomentation 
repeatedly  changed. 

External  Urethrotomy. — This  operation  is  performed  in  the 
following  way  :  A  staff  curved  in  the  shape  of  a  sound  and 
grooved  is  introduced  into  the  urethra,  and,  if  possible,  passed 
through  the  stricture. 

This  sound  is  now  held  in  a  vertical  position  in  the 
median  line  of  the  body  of  the  patient,  who  is  placed  in 
a  lithotomy  position.  The  operator  cuts  down  upon  the 
staff  until  the  bulbous  urethra  appears  in  the  wound.  The 
latter  is  then  pushed  upward  and  held  out  of  reach  by  a 
small  retractor.  Next,  by  means  of  the  pointed  knife,  the 
urethra  itself  is  split  open  and  all  the  stricturing  fibres  are 
severed.  The  little  finger  is  introduced  through  the  wound 
and  the  urethra  into  the  bladder,  in  order  to  determine  the  free 
permeability  of  the  prostatic  urethra.  After  this  is  done,  espe- 
cially if  cystitis  is  present,  a  drainage-tube  is  passed  through 
the  incision  into  the  bladder.  The  superfluous  part  of  the 
skin  incision  is  closed  by  a  few  stitches,  one  of  which  holds 
the  tube  in  position.  If  the  bladder  is  comparatively  unaf- 
fected, a  catheter  is   inserted  through  the  external  urethral 


132 


STRICTURE  OF  THE   URETHRA. 


Fig.  9. 


staff  or  grooved  ball- 
pointed  sound. 


orifice,  through  the  incised  urethra,  and 
then  into  the  bladder.  In  some  cases  a 
resection  of  the  urethra  can  be  performed ; 
again,  others  may  require  but  a  division  of 
the  stricturous  urethra ;  and  where  fistu- 
lous tracts  and  indurated  tissues  exist,  com- 
plete excision  of  the  affected  parts  is  indi- 
cated. If  a  catheter  has  been  inserted,  it 
should  be  left  in  place,  and  is  then  called 
"  permanent."  It  is  to  remain  in  the  blad- 
der for  varying  lengths  of  time  :  as  long  as 
increased  temperature,  due  to  the  cystitis, 
exists  it  may  remain  for  ten  to  twenty  days 
or  even  longer.  Of  course,  irrigations,  two 
or  three  times  a  day  if  necessary,  are  to  be 
given.  If  the  urine  is  clear  and  there  is  no 
rise  in  temperature,  it  may  be  removed  on 
the  second  or  third  day.  In  fact,  Koenig 
does  not  insert  either  catheter  or  drainage- 
tube  in  these  cases.  In  the  cases  without 
cystitis  sounding  can  be  proceeded  with 
at  once  and  is  to  be  done  daily.  Where  a 
catheter  is  in  place,  of  course  it  becomes 
unnecessary.  The  wound  is  but  partly, 
entirely,  or  not  at  all  sutured,  depending 
upon  the  severity  or  extent  of  the  opera- 
tive procedure. 

After  the  patient  is  brought  to  bed,  the 
catheter  or  drainage-tube  is  connected 
with  a  siphon  so  that  the  patient  is  kept 
dry.  In  cases  in  which  the  stricture  is 
not  passable  for  the  staff,  the  grooved 
sound  is  pushed  down  until  its  end 
reaches  the  stricture.  On  this  deciding 
point  the  operator  cuts  down  in  order  to 
find,  by  dissection,  the  central  free  end  of 
the  urethra  after  a  part  of  the  stricture  has 
been  divided.     Then  the  operation  is  fin- 


STRICTURE  OF  THE   URETHRA.  133 

ished  as  just  described.  It  must  not  be  forgotten  that  some- 
times the  roof  of  the  urethra  is  also  the  site  of  the  stricture. 
Hence  this  region  must  be  examined,  and  the  stricture  divided 
in  the  middle  line  if  necessary. 

Should  it  be  absolutely  impossible  to  find  the  posterior  end 
of  the  urethra  by  perineal  dissection, — and  sometimes  this 
becomes  a  most  difficult  piece  of  work, — the  bladder  must  be 
opened  through  a  suprapubic  incision  and  the  urethra  sounded 
by  introducing  an  instrument  into  it  from  the  bladder.  This 
procedure  is  called  retrograde  catheterization.  In  this  manner 
the  central  end  is  located  and  the  remaining  portion  of  the 
stricture  is  divided  or  excised.  Should  any  strictures  in  the 
anterior  urethra  be  present,  they  are  split  at  the  same  sitting 
by  internal  urethrotomy.  If  in  external  urethrotomy  ordi- 
nary strictures  are  encountered,  the  simple  division  of  these  is 
sufficient,  while  extensive  cicatrization  and  formation  of  callus 
call  for  excision  of  this  hardened  tissue. 

The  tube,  which  is  inserted  after  urethrotomy,  will  be  taken 
out  on  the  fourth  or  fifth  day  after  the  operation,  and  the 
patient  now  urinates  partially  through  the  urethra  and  par- 
tially through  the  perineal  fistula.  This  fistula  closes  up 
after  about  two  to  four  weeks,  during  which  time  sounds  are 
introduced  almost  daily  and  kept  up  at  irregular  intervals 
for  some  months  after  the  operation.  If  cystitis  has  been 
present  at  the  time  of  the  operation,  washing  of  the  bladder 
through  the  tube  or  catheter  is  kept  up  during  the  time  of 
convalescence,  and  salol  or  urotropin,  or  both,  administered 
internally,  as  outlined. 

Treatment  of  strictures  by  electrolysis,  as  already  stated,  should 
not  be  performed.  However,  it  is  best  to  explain  briefly  this 
method  :  There  are  differently  shaped  instruments  :  Lang  has 
devised  a  special  shape  of  sound  ;  the  tip  is  perforated,  allow- 
ing a  filiform  bougie  to  act  as  a  guide  for  the  grooved  sound  ; 
the  tip  is  metal,  and  the  rest  is  insulated.  Besides  this,  there 
are  olive-pointed  sounds  and  also  cutting-shaped  instruments. 
In  all  cases  this  should  be  the  negative  pole.  The  positive 
pole,  a  moistened  sponge,  can  be  placed  at  any  point,  but 
usually  over  the  pubes,  and  2  to  3   milliamperes  of  current 


134  STRICTURE  OE  THE   URETHRA. 

allowed  to  flow  for  some  five  to  ten  minutes.  During  this  time 
the  instruments  must  be  given  the  direction  desired.  For- 
merly 10  to  15  milliamperes  were  used  for  two  to  three  min- 
utes. The  tissue  destroyed  by  the  electrochemic  action  is  not 
necessarily  only  stricturous,  as  the  action  depends  entirely  on 
whether  the  instrument  takes  the  right  course.  It  is  true 
that  after  such  a  procedure  a  large  souud  may  be  immediately 
passed  and  the  patient  feel  fairly  well,  yet  in  the  course  of 
time  there  will  be  a  distinct  and  steady  contraction  following 
this  cauterization,  which  it  practically  is. 

Dividsion  is  a  method  which  should  not  be  used.  It  consists 
of  introducing  instruments  into  the  stricture  and  divulsing 
with  main  force.  The  instruments  have  the  shape  of  the 
modern  dilators,  although  these  have  to  a  certain  extent  been 
modeled  after  the  divulsors.  The  Le  Fort  method,  already 
mentioned,  is  practically  divulsion. 

Rapid  dilatation  can  be  performed  with  the  dilators  already 
described.  Here,  if  the  urethra  is  enormously  stretched  in 
one  sitting,  it  is  called  "  rapid."  But  these  dilators  are  not 
necessarily  used  in  this  manner,  and  Kollman  and  Oberlander 
both  advise  progressive,  gradual,  and  slow  dilatation  of  infil- 
trated areas,  exactly  as  with  the  sounds.  This  is  then  called 
"  progressive  "  dilatation. 

No  matter  which  type  of  treatment  is  instituted,  appropriate 
measures  in  the  way  of  irrigation  and  instillations  are  often 
necessary  throughout  the  entire  course  of  the  treatment. 

No  outline  can  be  made  for  all  cases,  yet  any  stricture  may 
be  treated  by  any  of  the  following  methods  :  dilatation,  slowly 
but  progressively,  or  rapidly  ;  divulsion,  electrolysis,  urethrot- 
omy, either  external  or  internal.  Divulsion  and  electrolysis 
should  positively  not  be  used,  hence  there  remain  but  few 
methods  that  can  be  utilized  in  the  various  types  of  stricture. 
However,  it  is  best :  (1)  To  dilate  all  soft  strictures,  whether 
in  the  anterior  or  posterior  urethra,  with  sounds  or  dilators, 
according  to  the  slow  but  progressive  methods  ;  (2)  all  fibrous 
strictures,  whether  anterior  or  posterior,  should  be  gradually 
dilated.  Belouging  to  this  class,  but  always  contracting,  are 
the  elastic  strictures.     Where  dilatation  does  not  afford  relief, 


STRICTURE  OF  THE   URETHRA.  ]35 

Fig.  10.  Fig.  11. 


ss(p5» 


Urethral  dilator  partially 
expanded. 


Urethral  dilator  partially 
expanded. 


lo6  COMPLICATION'S  OF   URETHRITIS. 

it  becomes  necessary  to  operate — if  the  stricture  is  in  the 
anterior  urethra,  an  internal  urethrotomy ;  if  in  the  posterior 
urethra,  an  external  urethrotomy  should  be  performed.  These 
same  procedures  are  to  be  carried  out  in  those  cases  where  a 
urethral  chill  follows  every  urethral  manipulation.  Wherever 
strictures  are  accompanied  by  severe  peri-urethritic  induration, 
fistula,  cystitis,  etc.,  it  is  best  to  perform  an  external  ure- 
throtomy. 

In  progressive  dilatation  metal  instruments  with  conical 
beaks  are  best  because  they  enter  the  stricture  most  easily 
and  are  most  efficacious. 

Complications  of  Urethritis. 

Other  complications  during  the  course  of  an  acute  or  chronic 
affection  of  the  urethra  besides  those  already  mentioned  are 
inflammatory  conditions  of  the  urethral  glands  and  the  in- 
volvement of  organs  which  are  attached  to  it. 

(Edema  of  the  Foreskin. 

This  is  not  uncommon  in  the  course  of  an  acute  gonorrhoea. 
It  may  be  very  marked.  It  must  be  due  to  an  obstruction 
of  the  lymphatic  flow.  In  these  cases  all  local  urethral  treat- 
ment should  be  stopped,  and  antiphlogistic  treatment  intro- 
duced. 

Urethral  Folliculitis. 

Symptoms. — In  every  acute  inflammation  of  the  urethra 
the  urethral  follicles  are  involved  to  some  degree,  although 
this  may  occur  during  the  chronic  stages.  In  most  cases 
no  marked  affection  exists  and  no  symptoms  arise,  but  when 
one  or  more  are  attacked,  they  can  readily  be  found  by 
palpation,  especially  as  they  are  usually  in  the  floor  of  the 
urethra.  If  as  large  as  a  pea,  inspection  shows  a  bulging 
along  this  part.  Even  after  reaching  these  dimensions  they 
may  subside  spontaneously,  or  the  dilated  follicles  may  de- 
velop into  an  abscess  and  the  contents  break  through  the 
skin  (occasionally  a  fistula  results)  or  through  the  duct  into 


cow  PER' S  GLANDS.  137 

the  urethra.  If  the  inflammation  extends  to  the  cellular 
tissue,  a  peri-urethral  imflammation  sets  in,  the  abscess  be- 
comes more  diffuse  and  may  break  in  either  or  both  direc- 
tions, and  fistula  remains.  This  latter  condition  is  often 
accompanied  by  chills,  fever,  sweats,  and,  if  of  a  very 
severe  type,  all  the  signs  of  sepsis  persist. 

The  treatment  must  always  be  antiphlogistic.  Give  the 
parts  rest  and  moist  applications — at  first  cold,  and  later 
warm.  Avoid  all  local  irritation  and  prevent  erections.  All 
injections  are  best  omitted,  although  carefully  given  warm 
irrigations  of  mild  1:15,000  bichloride  of  mercury  or  satu- 
rated boric  acid  solution  may  be  given.  If  resolution  sets  in, 
a  sound  may  be  introduced  and  the  gland  massaged.  This 
should  be  kept  up  until  all  traces  disappear. 

However,  should  the  abscess  point  toward  the  skin,  a  small 
incision  and  packing  the  cavity  with  iodoform  gauze  and  moist 
dressings  are  to  be  continued.  If  just  within  the  glans,  the 
affected  follicles  can  occasionally  be  treated — incised,  if  neces- 
sary, through  a  urethroscopic  tube.  Iodoform  and  ichthyol, 
2  grains  of  each  to  each  urethral  bougie,  may  be  used  several 
times  a  day. 

Cowper's  G-lands. 

These  glands,  emptying  into  the  bulbous  urethra  and  sit- 
uated just  at  the  perineal  region,  occasionally  become  involved 
during  either  an  acute  or  a  chronic  attack  of  urethritis. 

Symptoms. — Pain  is  the  initiative  symptom,  and  as  only 
one  gland  is  most  often  affected,  the  swelling  wdll  be  seen 
on  that  side. 

Treatment. — If  antiphlogistic  treatment  is  begun  and  if 
local  urethral  treatment  be  stopped  at  once,  resolution  often 
will  occur.  However,  suppuration  can  readily  occur.  If 
the  swelling  becomes  diffuse,  passing  into  the  surrounding 
tissue,  the  swelling  may  become  quite  large,  painful,  and 
fluctuation  may  set  in.  This  is  referred  to  as  a  peri-Cowper- 
itis.  Whenever  it  reaches  this  point,  a  free  longitudinal  in- 
cision becomes  necessary.  Occasionally  a  fistula  is  estab- 
lished.      A  chronio    Cowperitis  may   persist ;    only  a   small 


138  COMPLICATIONS   OF   URETHRITIS. 

and  painful  nodule  may  remain.     In  these  cases  excision  can 
be  recommended. 

Tuberculosis  and  malignant  disease  of  this  gland  have  been 
noted,  but  are  exceedingly  rare. 


Inflammation  of  the   Seminal  Vesicles    (Seminal  Vesiculitis    or 
Spermato-cystitis ) . 

Symptoms. — Inflammation  readily  follows  in  acute  or 
chronic  posterior  urethritis.  It  rarely  exists  by  itself,  but 
is  nearly  always  accompanied  by  a  prostatitis,  and  frequently 
by  an  epididymitis.  An  acute  attack  is  manifested  by  a  slight 
pain  in  the  perineum,  which  pain  may  extend  down  the  thigh 
or  even  into  the  scrotum.  There  is  pain,  which  may  be  of 
shooting:  character,  on  defecation.  Pollutions  are  also  accom- 
panied  by  pain.  In  chronic  affections  the  symptoms  are 
the  same  as  in  acute  cases,  but  not  so  marked.  Besides, 
there  may  be  too  frequent  erections,  and  during  intercourse 
pain  in  the  back  and  ejaculatio  yrcecox  may  be  a  symptom.  In 
both  the  acute  and  the  chronic  forms  the  contents  of  seminal 
vesicles  are  mixed  with  red  blood-corpuscles.  Besides  these, 
there  may  occur  slight  urinary  symj^toms.  Often  these  cases 
are  associated  with  neurasthenic  symptoms.  Once  in  a  while 
an  abscess  may  form  and  break  into  the  urethra,  rectum,  or 
abdominal  cavity.  By  the  rectal  examination  the  vesicles 
either  on  one  or  both  sides  may  most  often  be  palpated  as  dis- 
tended, fluctuating,  and  painful  sacs ;  and  the  duct  passing 
through  the  prostate  and  vesicle  itself  above  and  on  the  base 
of  the" bladder  are  to  be  felt.  Again,  especially  in  the  chronic 
cases,  the  vesicles  can  be  felt  in  the  area  described  as  irregu- 
larly nodulated  masses.  Here  the  Posner  three-glass  method, 
which  gives  the  so-called  expression  urine,  should  be  used,  and 
the  microscopical  findings  shoidd  be  as  already  described. 

Tuberculosis  of  these  organs  occurs  rarely  alone,  but  com- 
monly associated  with  tuberculosis  of  the  epididymis  and 
prostate  gland. 

The  treatment  here,  as  in  all  other  inflammatory  affections, 
is  to  prevent  the  process  from  going  on  to  suppuration.     All 


DISEASES  AND  TUMORS  OF  THE  PROSTATE  GLAND.     139 

sexual  excitement  should  be  avoided  ;  the  pelvis  depleted ; 
free  bowel  movements  obtained ;  hot  sitz-baths  and  alkaline 
diluents  advised.  Suppositories  are  to  be  used  regularly, 
such  as — 

^i     Ext.  belladonnse,  0.25  gramme; 

Ichthyolis, 

lodoliSj^  aa        2.50  grammes ; 

Butyrse  cocse,         q.  s. 
M.  et  ft.  in  sup.  rect.  No.  x. 
Sig. — Insert  two  or  three  each  day. 

When  the  acute  stage  is  over,  massage  of  the  seminal 
vesicles,  regularly  given,  and  rectal  injections  of  warm  saline 
solutions  are  to  be  recommended.  The  term  "dripping^'  has 
been  used  to  describe  massaging  the  seminal  vesicles  ;  it  must  be 
continued  for  weeks  and  even  months,  in  connection  with  all 
antiphlogistic  treatment,  especially  mentioning  the  Arzberger 
cooling  apparatus,  in  order  to  gain  any  headway.  If  abscess 
has  formed,  it  is  best  to  use  surgical  methods.  To  reach  the 
seminal  vesicles  the  best  incision  is  either  the  Fuller  or  the 
Zuckerkandl,  which  will  be  described  under  Prostatic  Dis- 
eases. 

DISEASES  AND   TUMORS  OF  THE  PROSTATE 
GLAND. 

The  prostate  gland  is  a  glandular  body  which  surrounds 
the  central  end  of  the  urethra  and  forms  the  so-called  pros- 
tatic urethra.  The  prostate  consists,  chiefly,  of  muscular 
tissue  in  which  numerous  small  glands  are  embedded.  These 
glands  terminate  with  their  ducts  around  the  caput  gallinagi- 
nis.  The  body  of  the  prostate  is  perforated  by  the  two 
ejaculatory  ducts.  The  prostate  has  two  lateral  lobes,  which 
are  connected  by  a  median  bar.  The  whole  gland  is  covered 
l)y  a  fibrous  capsule.  It  is  kept  in  its  place  chiefly  by  the 
posterior  layer  of  the  triangular  ligament.  The  function  of 
the  prostate  is  to  help  in  the  ejaculation  of  semen  after  it  is 
collected  in  the  prostatic  urethra,  while  the  secretion  of  the 


140     DISEASES  AND  TUMORS  OF  TEE  PROSTATE  GLAND. 

prostate  is  the  necessary  accessory  for  the  activity  of  the 
spermatozoa.  The  prostate  may  be  changed  by  hypertrophy, 
by  gonorrhceal  inflammation,  by  tuberculosis,  neoplasms,  and 
calcareous  deposits  in  its  parenchyma. 

Acute  Prostatitis. 

The  term  acute  prostatitis  is  often  used.  This  usually  com- 
plicates specific  or  non-specific  urethritis.  It  is  most  frequently 
probably  a  sequence  of  chronic  posterior  urethritis.  Ex- 
cesses are  possible  causes  of  this  condition.  It  is  in  these 
particular  cases  that  acute  signs  of  a  posterior  urethritis  are 
either  present  a  short  time  before  or  not  infrequently  in  con- 
junction with  this  condition  by  simultaneous  infection.  For 
more  practical  purposes,  acute  prostatitis  can  be  divided  into 
two  divisions — viz.: 

1.  Acute  prostatitis  of  the  entire  gland. 

2.  Acute  follicular  prostatitis. 

Acute  General  Prostatitis. 

Symptoms. — In  these  particular  cases  it  is  possible  to  find 
practically  per  rectum  only  very  slight  enlargement  or  oedema 
of  the  prostate.  It  is  usually  small,  regularly  shaped,  a  little 
softer  in  consistency  than  normal,  and  but  slightly  painful. 
On  examination  by  the  three-glass  method  the  patient  is 
allowed  to  urinate  into  the  third  glass,  and  on  examination 
of  the  sediment  microscopically  pus  is  either  present  or 
absent.  If  present  with  prostatic  elements,  there  must  be 
a  prostatitis  present.  This  is  the  only  way  to  diagnose  acute 
prostatitis.  It  can  involve  the  whole  structure  of  the  pros- 
tate. The  symptoms  are  practically  the  same  as  those 
enumerated  in  acute  posterior  urethritis,  but  in  addition 
there  are  much  pain  in  the  perineum,  slight  pain  in  the 
rectum,  and  oftentimes  pain  on  defecation. 

Treatment. — Rest.  No  sexual  excitement.  Diet  mild, 
nothing  stimulating,  no  highly  spiced  foods  ;  none  other  than 
bland  foods.     Deplete  the  bowels.     Anodynes  and  treatment 


ACUTE  FOLLICULAR  PROSTATITIS.  141 

like  that  for  the  posterior  urethritis.     Of  late,  heroin  in  the 
form  of  suppository  has  been  recommended: 

]^     Heroini  hydrochloratis,  0.1  gramme ; 

Butyri  cocse,  q.  s. 
Ft.  in  suppos.  No.  x. 
Sig. — Insert  one  every  four  hours. 

A  differentiation  is  scarcely  ever  made  from  an  acute  posterior 
urethritis. 

Acute  Follicular  Prostatitis. 

The  second  class  of  cases  is  more  easily  diagnosed  and  more 
necessary  to  recognize.  It  is  probably  the  most  common 
kind  of  prostatitis  that  sets  in,  following  posterior  urethritis. 
The  follicles  are  involved  more  or  less  deeply,  causing  the 
prostatic  urethra  to  become  more  swollen  and  congested,  de- 
pending upon  the  depth  that  the  inflammation  extends,  causing 
irregularity  of  the  prostate  when  examined  per  rectum.  The 
inflammation  extends  down  from  the  urethra  to  the  ducts 
of  the  prostate,  occludes  these  openings,  and  causes  the  fol- 
licles to  enlarge — pseudo- abscesses.  These  plugs  oftentimes 
loosen  and  are  passed  at  the  time  of  urination,  and  in  doing 
so  small  quantities  of  pus  escape.  If  the  inflammation  con- 
tinues and  becomes  chronic,  scar  tissue  forms,  and  the  whole 
glandular  tissue  is  more  or  less  destroyed. 

Symptoms. — These  cases  of  follicular  prostatitis  show  fre- 
quent desire  for  urination  which  often  become  imperative. 
Frequently  after  urination  the  desire  to  urinate  still  con- 
tinues, sometimes  for  minutes,  perhaps  constantly  for  hours. 
Usually  at  the  end  of  urination  pain  exists,  and  small  quan- 
tities of  blood  or  pus  are  passed.  The  two-  and  three-glass 
methods  should  be  used  in  making  the  diagnosis. 

As  to  the  rectal  findings  :  In  this  particular  kind  of  in- 
flammation of  the  prostate  a  pea-shaped  enlargement  over 
the  prostatic  surface  will  usually  be  found,  making  this 
surface  very  irregular  and  exceedingly  painful.  This  is 
in  strong  distinction  to  tuberculosis,  where  the  nodules  over 


142    DISEASES  AND  TUMORS  OF  THE  PROSTATE  GLAND. 

the  gland  surface  are  entirely  different,  much  smaller,  and 
closer  together  and  usually  painless. 

It  is  in  these  cases  that  the  sexual  physiology  is  often 
affected.  If  the  ejaculatory  duct  becomes  affected  and  an 
obstruction  forms,  the  patient  oftentimes  complains  of  great 
pain  at  the  time  of  pollution.  If  the  condition  becomes 
chronic  and  there  is  complete  closure  of  one  of  the  ejaculatory 
ducts,  the  patient  is  ever  afterward  a  sufferer  from  oligo- 
spermia— a  lessening  of  the  spermatozoa.  Should  both  of 
these  ejaculatory  ducts  which  pass  through  the  lobes  of  the 
prostate  become  closed,  then  the  patient  would  be  ever  after- 
ward sterile.  It  is  one  of  the  causes  of  sterility  in  man, 
asperm,atismus,  or  complete  absence  of  the  spermatozoa. 

Parenchymatous  Prostatitis. 

Symptoms. — On  rectal  examination  the  lobes  are  found 
more  or  less  enlarged,  rounded,  oedematous,  consistency 
softer,  pain  severe,  throbbing  in  the  mass,  but  no  fluctua- 
tion. If  this  condition  remains  for  any  length  of  time, — 
say  a  week, — usually  an  abscess  formation  occurs.  There- 
fore there  is  a  fusing  of  some  of  these  inflammatory  foci, 
and  instead  of  this  throbbing  condition  a  fluctuating  mass 
appears.  The  diagnosis  of  abscess  of  the  prostate  is  made 
only  where  there  is  fluctuation. 

Abscess  of  the  Prostate. 

Pathology. — These  pus-sacs  or  foci  run  together  and  may 
become  of  large  size,  and  thus  form  one  abscess.  The  pros- 
tatic gland  is  often  entirely  destroyed,  as  it  is  included  in 
practically  one  abscess.  The  tissue  around  the  base  of  the 
bladder  to  which  the  seminal  vesicles  are  attached  is  then 
involved,  and  the  whole  part  which  lies  between  the  rectum 
and  the  bladder  is  finally  massed  together,  and  the  fluctu- 
ation can  be  felt  as  a  localized  area  or  may  be  very  diffuse. 
If  an  abscess  is  left  untreated,  it  may  break  or  empty  itself 
through  the  urethra,  which  condition  is  most  common.  In 
fact,  this  often  fills  up,  may  refill  itself,  or  in  the  course  of 


ABSCESS  OF  THE  PROSTATE.  143 

time  the  opening  leading  into  the  urethra  becomes  patent, 
and  this  then  accounts  for  urinary  dribbling  as  the  urine 
passes  into  an  old  pus-sac.  It  may  extend  around  the 
rectum  and  become  a  periprostatic  abscess,  may  break  into 
the  rectum,  or  into  any  number  of  other  directions, — toward 
the  perineum,  ischio-rectal  space,  cavum  Retzii,  etc., — bat  the 
most  common  are  the  three  through  the  urethra,  rectum,  or 
perineum,  in  the  order  named. 

Symptoms. — At  the  beginning  there  are  chills  and  feyer, 
chilliness,  flushes  of  heat,  etc.  With  coalescence  of  these 
different  foci — all  the  signs  of  a  pyemia ;  pain  in  the  peri- 
neum, of  a  dull,  dragging  character,  often  intense.  The  pain 
with  tenesmus  is  intense.  During  urination  there  is  a  burning 
pain,  and  at  the  end  there  are  always  pain  and  tenesmus,  per- 
haps also  some  blood  and  pus  at  the  end  of  urination. 

The  region  between  the  rectum  and  the  prostate  and  the 
lower  part  of  the  bladder  occasionally  becomes  affected,  and 
then  the  so-called  periprostatic  phlegmons  and  phlebitis  occur. 
The  whole  mass  does  not  fluctuate. 

Phlebitis  can  occasionally  be  felt  per  rectum  as  strands. 

Diagnosis  of  phlebitis  can  be  made  only  by  rectal  examina- 
tion, when  cord-like  strands  corresponding  to  the  hemorrhoidal 
veins  are  felt. 

Diagnosis  of  Follicular  Prostatitis. — Always  keep  in  mind 
the  increased  urgency  and  frequency  of  urination,  of  pains, 
of  the  pus  at  the  end  of  urination,  of  the  stopping  of  pus  at 
the  external  urethral  orifice  if  the  onset  is  acute.  Use  the 
two-glass  method. 

Diagnosis  of  Acute  Parenchymatous  Prostatitis. — When  the 
entire  gland  is  involyed,  there  are  constitutional  symptoms, 
chills,  and  fever ;  these  may  occur  repeatedly.  The  fre- 
quency of  urination  is  increased,  just  as  in  follicular  prosta- 
titis, but  there  is  usually  much  more  difficulty  when  passing 
urine.  Pain  is  much  more  severe.  The  findings  of  rectal 
examination  are  as  already  outlined. 

Treatment  of  follicular  prostatitis  is  absolutely  like  that  of 
acute  posterior  urethritis,  which  treatment  has  already  been 
described. 


1-44     DISEASES  AND  TUMORS  OF  THE  PROSTATE  GLAND. 

Treatment  of  Acute  Parenchymatous  Prostatitis. — In  this 
an  attempt  to  prevent  suppuration  is  made.  Sitz-baths,  hot 
applications  to  the  perineum,  rectal  irrigations  with  small 
quantities  of  water — a  cupful  of  water  at  a  time,  allowing 
the  water  to  remain  in  the  rectum  a  while.  Add  3  to  5  c.c. 
of  ichthyol  to  each  cup  of  water.  Apply  dry  cups,  blisters, 
and  leeches  to  the  perineum.  Put  the  patient  to  bed.  Feed 
him  on  plain,  bland  diet.  Give  alkaline  diuretics  and  all  the 
anodynes  that  are  needed.  If  retention  of  urine  occurs, 
catheterize  under  aseptic  precautions.  Always  try  to  insert 
as  small  and  soft  a  rubber  catheter  as  possible.  It  is  abso- 
lutely necessary  to  carry  out  this  treatment  for  a  case  of 
acute  parenchymatous  prostatitis,  because  the  latter  is  the 
forerunner  of  an  abscess. 

If  fluctuation  is  felt,  it  is  necessary  to  proceed  at  once  to 
empty  the  abscess. 

Do  not  ica'dfor  an  abscess  to  break,  but  advise  operative  in- 
terference. 

There  are  two  ways  to  do  this  : 

1.  Puncture  through  the  rectum.  The  finger  is  introduced 
into  the  rectum  with  the  tip  on  the  fluctuating  mass.  The 
trocar  is  passed  along  the  finger  and  suddenly  pushed  into 
the  most  prominent  part  of  the  fluctuating  area.  This  is  not 
to  be  advocated,  but  may  be  used  in  certain  cases. 

2.  Zuckerkandl's  incision:  The  patient  is  in  the  lithotomy 
position.  In  cases  of  abscess  a  soft-rubber  catheter,  in  other 
cases  a  metal  catheter,  may  be  introduced  into  the  urethra  in 
order  to  outline  its  course.  The  operator  should  insert  the 
index-finger  of  his  left  hand  wdth  rubber-glove  protection 
into  the  rectum,  and  make  a  semilunar  incision  extending 
between  the  tuberosities  of  the  ischii  and  crossing  the  median 
line  midway  between  anus  and  scrotum,  through  the  skin, 
subcutaneous  tissue,  and  fascia,  and  cutting  through  the 
superficial  transversus  perinei  muscle  and  the  sphincter  and 
the  bulbo-cavernosus  muscles ;  then,  with  blunt  dissection, 
separate  the  anterior  rectal  wall  from  the  prostate.  If  the 
case  is  a  prostatic  abscess,  an  incision  is  made  in  the  most 
prominent  fluctuating  point,  parallel  to  the  urethra.     Drain- 


CHRONIC  PROSTATITIS.  145 

age  and  packing  with  iodoform  gauze  must  be  secured.  For 
prostatectomy,  the  removal  of  tuberculous  or  malignant 
growths  of  the  seminal  vesicles,  this  same  incision  can  be 
used. 

Treatment  of  Secondary  Phlebitis. — Try  to  subdue  the  in- 
flammation. Use  all  kinds  of  antiphlogistics  to  reduce  the 
inflammation.  Local  treatment  in  the  way  of  irrigations  per 
rectum,  with  the  addition  of  ichthyol.  If  the  thrombus 
becomes  infected,  then  operate. 

Chronic  Prostatitis. 

Symptoms. — This  disease  always  follows  a  posterior  ure- 
thritis. Oftentimes  there  is  a  slight  discharge  at  the  external 
urethral  orifice.  In  these  cases  there  is  usually  a  slight  burn- 
ing on  urination,  pain  on  erection,  too  many  pollutions,  too 
many  erections,  pain  at  the  time  of  ejaculation  or  during  the 
sexual. act ;  perhaps  pain  radiating  down  the  legs.  Oftentimes 
there  is  scarcely  any  symptom  whatever  in  these  cases.  The  only 
signs  may  be  the  so-called  nervous  phenomenon.  The  patient 
is  a  sufferer  from  all  kinds  of  psychical  disturbances ;  there 
may  be  sexual  debility,  neurasthenia,  and  depression.  Another 
symptom  that  may  be  present  is  some  slight  heat  or  bearing- 
down  pain  in  the  perineum  ;  at  times,  radiating  pain  down 
the  legs.  Furthermore,  pains  at  the  time  of  pollution  or 
during  the  sexual  act  occur.  All  these  cause  the  patient  to 
concentrate  his  thoughts  upon  these  symptoms  and  to  bring 
about  a  condition  of  neurasthenia.  This  may  be  the  cause 
of  premature  ejaculation  (ejaculatio  -prematura).  Sterility  is 
often  caused  by  this  condition  of  affairs.  Rectal  examination 
of  the  prostate  may  be  painful,  though  not  always  so. 

Diagnosis. — This  must  be  made  by  microscopical  examina- 
tion of  the  urine  and  of  the  "  expressed  "  discharge ;  also  by 
rectal  examination. 

Treatment. — The  treatment  consists  of  local  measures, 
especially  massaging  the  prostate,  irrigation  of  posterior  ure- 
thra, occasionally  putting  in  a  sound  of  large  calibre,  and 
instillations.     At   the   same  time    sitz-baths,   local    douches, 

10— V.  D. 


146     DISEASES  AND  TUMORS  OF  THE  PROSTATE  GLAND. 

enemata,  and  suitable  diet  are  indicated.  Should  this  local 
treatment  not  be  sufficient  to  clear  up  the  urine,  a  dilator 
should  be  gently  and  progressively  used  to  stretch  the  posterior 
urethra,  open  up  the  ducts  of  the  prostate  in  this  way,  and 
then  irrigation  should  be  begun,  in  order  to  remove  the  plugs 
of  material  that  are  remaining  in  the  gland. 

The  internal  treatment  is  exactly  the  same  as  in  chronic 
anterior  affections.  During  the  whole  course  of  the  treatment 
give  urinary  antiseptics.  A  few  suppositories  which  may  be 
used  per  rectum  are  : 

Ki     Potassii  iodidi,  0.50  gramme  ; 

lodi  puri,  0.05       " 

Ext.  belladonnse,  0.10       " 

Butyrse  cocse,  q.  s. 

M.    Ft.  in  sup.  rect.  No.  x. 

^     Potassii  iodidi,  10.00  grammes  ; 

Potassii  bromidi,  10.00         " 

Ext.  belladonnse,  0.25  gramme  ; 

Aquse,  300.00  grammes. 

M.  &  S. — For  20  rectal  enemata. 

One  may  also  add  to  each  injection  from  2  to  10  drops  of 
tincture  of  iodine,  or  2  or  3  grammes  of  ichthyol  at  the  time 
of  each  injection. 

If  the  signs  of  congestion  are  severe  in  the  posterior  ure- 
thra, with  severe  burning  on  urination,  use  an  application  of 
iodine,  1  or  5  per  cent,  in  glycerin,  with  an  Ultzmann  or  Guyoa 
instrument. 

Whenever  there  is  chronic  affection  of  the  prostate  or  sem- 
inal vesicles,  moist  heat  is  very  necessary.  This  should  be 
applied  with  hot-water  rectal  douches,  with  the  aid  of  dif- 
ferently shaped  tubes  originally  introduced  by  Arzberger. 
Occasionally,  when  abscess  formation  is  to  be  aborted,  the 
prostate  cooler  should  be  employed.  This  is  a  self-retaining, 
somewhat  pear-shaped,  metal  instrument.  Its  flattened  sur- 
face is  to  be  placed  against  the  gland  and  cold  water  allowed 


HYPERTROPHY  OF  THE  PROSTATE  GLAND.        147 

to  pass  through   the   separated   chambers  for  ten   to   fifteen 
minutes,  five  to  ten  times  a  day. 

DiFFEEENTIAL    DIAGNOSIS    BETWEEN    AcUTE     POSTEEIOE     UeETHEITIS   AND 

Acute  Peostatitis. 
Acute  Posterior  Urethritis.  Acute  Prostatitis. 

1.  Frequent  urination.     Tenesmus.       1.  Urination  not  so  often.     Tenesmus 

usually  absent. 

2.  Pain  at  end  of  urination.  2.  Absent. 

3.  Blood  or  pus  or  both  at  end  of  uri-  3.  Absent. 

nation. 

4.  Slight  pain  in  perineum.  4.  Severe,  deep  pain  in  perineum.  Pain 

often  severe  in  rectum,  especially 
during  defecation. 

5.  Absent.  5.  Eetention. 

6.  Seldom  fever ;    usually  no  very  se-  6.  Severe  general  symptoms. 

vere  symptoms. 

7.  Eectal  examination  :  slightly  cede-  7.  Enlarged  and  painful  prostate. 

matous.     Often  normal  prostate. 


Hypertrophy  of  the  Prostate  Gland. 

Hypertrophy  of  the  prostate  is  the  enlargement  of  the 
gland  by  formation  of  new  tissue.  These  enlargements  may 
either  be  uniform,  so  that  the  body  and  both  lobes  become  en- 
larged, or  be  confined  to  only  one  lobe  or  to  the  body,  or  the 
hypertrophy  is  a  partial  one,  in  the  sense  that  a  circumscribed 
hypertrophy  in  one  of  the  parts  of  the  prostate  takes  place. 
The  enlargement  of  the  connecting  bar  is  known  as  Home's 
lobe.  The  hypertrophy,  if  existing  mostly  around  the  pros- 
tatic urethra  as  nodules  protruding  into  the  urethral 
lumen,  may  make  the  course  of  the  urethra  tortuous,  thus 
interfering  with  the  urinary  stream.  These  nodules  are  occa- 
sionally felt  next  to  the  sphincter  ani.  If  the  lobes  hyper- 
trophy toward  the  rectum,  they  can  be  felt  by  rectal  palpation. 
The  protrusion  of  the  lobes  or  of  the  connecting  bar  into  the 
bladder  can  be  diagnosed  only  by  instrumental  examination — 
that  is,  by  cystoscopy  or  by  the  diagnostic  sound  and  also  by 
the  stone  sound.  The  hypertrophy  of  the  prostatic  body 
elongates  the  prostatic  urethra  to  a  considerable  extent,  while 
the  lobes  which  protrude  into  the  bladder  prevent  its  com- 
plete emptying.     The  median  lobe  forms  a  wall  between  the 


148     DISEASES  AND  TUMORS  OF  THE  PROSTATE  GLAND. 

trigonum,  the  bos  fond,  and  the  internal  urethral  orifice.  This 
difference  in  the  level  is  the  reason  that  this  part  cannot  have 
an  unimpeded  outflow.  The  consequence  is  that  in  cases  of 
prostatic  hypertrophy  a  residual  urine  is  always  encountered 
— that  is,  immediately  after  a  patient  urinates  naturally  if  a 
catheter  is  then  introduced,  a  variable  quantity  of  urine  is 
found  to  be  present  in  the  bladder,  which  cannot  be  passed 
voluntarily.  Further  symptoms  are  a  frequent  desire  for 
urinating,  especially  during  the  night ;  also  inability  to  start 
urination  at  once,  but  the  patient  must  wait  and  exert  pres- 
sure, and  suffer  inconvenience  during  the  passage  of  feces. 

Diagnosis. — The  diagnostic  points  in  prostatic  hypertrophy 
are  the  elongation  of  the  urethra,  residual  urine,  and  the 
proof  of  enlargement  of  the  gland   or  some  of  its  parts. 

Treatment. — Palliative  or  a  radical  means  are  applicable. 

Palliative  treatment  consists  in  inserting  large  sounds  and 
regular  catheterization,  and  the  regular  flushing  out  of  the 
bladder,  especially  if  cystitis  is  present.  If  these  measures 
are  kept  up  for  some  time,  considerable  relief  can  be  furnished. 
But  after  a  while  the  symptoms  will  recur  and  the  treatment 
must  be  repeated.  If  satisfactory  voluntary  urination  is  im- 
possible and  radical  treatment  for  some  reason  is  excluded, 
the  patient  has  to  lead  what  is  called  a  catheter  life.  The 
urine  must  be  drawn  in  regular  intervals,  and  the  patient 
must  be  instructed  in  the  use  of  the  catheter  and  to  use  all 
aseptic  precautions.  It  is  nothing  unusual  that  the  common 
catheter  cannot  be  introduced  in  cases  of  prostatic  hyper- 
trophy ;  then  catheters  whose  consistency  and  curve  enables 
them  to  pass  over  the  obstruction  must  be  used.  Either  elas- 
tic catheters  with  a  sharp  angle  at  the  beak  (catheter  coude  or 
Herder)  or  silver  catheters  with  an  elongated  beak  are  to  be 
used. 

If  catheterization  is  impossible  and  radical  treatment  is  not 
feasible,  a  permanent  suprapubic  fistula  is  to  be  established. 

The  radical  treatment  of  prostatic  hypertrophy  is  either  a 
severing  of  the  obstacle  (prostatotomy)  or  the  extirpation  of 
the  obstructing  hypertrophied  parts  [prostatectomy).  The  so- 
called  modern  procedure  is  a  galvanocaustic  incision  of  the 


HYPERTROPHY  OF  THE  PROSTATE  GLAND.        149 
Fig.  12.  Fig.  13. 


LeFort's  catheter  with  filiform  guide  attached  for 
passing  irregular  strictures  and  enlargements 
of  the  prostate. 


Pezzoli's  instrument  for  mas- 
sage of  the  prostate. 


150     DISEASES  AND  TUMORS  OF  THE  PROSTATE  GLAND. 

obstructing  lobes,  an  operation  which  is  called  after  its  in- 
ventor, BottinVs  operation.  Bottini's  incisor,  modified  by 
Freudenburg,  is  an  instrument  shaped  like  a  long  sound.  In 
the  groove  which  runs  through  its  shank  from  the  handle  to 
the  end  a  piston  slides,  to  whose  central  end  a  gal  van  oca  us  tic 
blade  is  attached.  This  blade  can  be  entirely  hidden  in  the 
beak,  and  when  desired,  is  drawn  toward  the  distal  end  of  the 
instrument  by  means  of  a  screw  which  is  attached  to  the 
handle.  A  leaden  hose,  which  runs  through  the  whole  length 
of  the  instrument,  enables  iced  water  to  run  through  the 
instrument  in  order  to  keep  the  shaft  cool  during  the  oper- 
ation. The  incision  itself  is  performed  in  the  following 
manner :  The  bladder  is  dilated  to  a  small  degree  by  means 
of  water  or  air ;  then  the  instrument  is  introduced,  and  the 
beak  turned  downward  or  sideward  into  contact  with  the  part 
of  the  obstructing  lobe  which  is  to  be  incised.  When  the 
instrument  is  hooked  against  the  lobe,  the  cooled  water  is 
turned  on,  after  which  an  electric  current  is  set  in  play.  Most 
operators  control  the  position  of  the  beak  during  an  operation 
by  one  finger  inserted  into  the  rectum.  After  the  current  is 
turned,  the  glowing  blade  is  slowly  passed  through  the  desired 
part  by  using  the  screw  on  the  handle.  After  one  lobe  is 
severed  the  blade  is  returned,  the  current  is  turned  off,  and 
the  next  obstructing  lobe  is  severed  in  the  same  way.  While, 
as  a  rule,  this  operation  is  done  under  general  anaesthesia, 
there  are  patients  who  are  tolerant  enough  to  allow  of  being 
operated  on  under  local  anaesthesia ;  25  c.c.  of  a  4  per  cent, 
antipyrin  solution  are  injected  into  the  bladder  and  0.015 
gramme  of  morphine  in  a  suppository  is  inserted  into  the 
rectum.  The  after-treatment  is  very  simple.  The  patient  is 
catheterized  only  in  case  of  necessity,  but  if  the  catheter  must 
be  used  once,  it  is  best  to  leave  it  in  for  a  few  days  in  order  not 
to  tear  off  the  eschars.  The  patient  should  have  rest,  urinary 
antiseptics,  and  antiphlogistic  treatment,  instituted.  Compli- 
cations, as  hemorrhages,  periprostatic  abscesses,  and  urinary 
infiltrations  may  occur  if  the  operation  is  not  carefully  carried 
out.    One  caution  of  the  Bottini  operation  is  to  make  the  cuts 


HYPERTROPHY  OF  THE  PROSTATE  GLAND. 


151 


slowly.  If  the  blade  is  drawn  along  too  rap- 
idly, then  the  after-hemorrhage  is  apt  to  be 
very  much  greater. 

Prostatectomy  may  be  performed  either 
through  a  suprapubic  incision  or  by  the  peri- 
neal route. 

The  perineal  operation  is  performed  in  the 
following  manner :  The  patient  is  placed  in 
the  lithotomy  position,  and  the  prostate  made 
accessible  either  through  a  semicircular  inci- 
sion around  the  anus  or  through  an  incision 
in  the  perineal  raphe.  After  the  prostate  is 
reached  through  blunt  dissection,  the  main 
point  is  to  split  open  the  fibrous  capsule  of 
the  gland.  After  this  is  done  it  is  rather  easy 
to  shell  out  the  enlarged  lobes  without  endan- 
gering the  bladder-wall.  The  prostatic  urethra 
will  always  be  torn  to  a  certain  extent,  although 
this  is  to  be  avoided  as  much  as  possible.  In 
order  to  make  the  prostate  more  accessible,  a 
large  sound  may  be  introduced  into  the  blad- 
der, and  by  means  of  this  instrument  the  gland 
is  pushed  down  toward  the  perineum.  Some 
operators  add  to  the  perineal  incision  a  supra- 
pubic one,  either  entering  or  remaining  with- 
out the  bladder,  in  order  to  push  the  prostate 
down  through  the  latter  opening.  The  simplest 
means  is  to  have  an  assistant  press  the  gland 
downward  toward  the  operator  through  the  ab- 
dominal parietes.  After  the  gland  is  removed, 
a  drainage-tube  is  inserted  through  the  perineal 
incision  into  the  bladder,  through  which  the 
bladder  is  regularly  flushed  out  with  antiseptic 
solutions.  This  tube  may  be  removed  after  the 
wound  is  entirely  filled  with  healthy  granula- 
tions. 

Suprapubic  prostatectomy  is  done  in  this  way  : 
After  the  suprapubic  opening  into  the  bladder 


Fig.  14. 


Bottini's 
prostatotome. 


152     DISEASES  AND  TUMORS  OF  THE  PROSTATE  GLAND. 

is  made  and  the  base  of  the  bladder  rendered  accessible  by 
the  insertion  of  retractors,  the  mucous  membrane  covering 
the  enlarged  lobes  is  incised,  and  the  obstructing  parts  are 
shelled  out  after  the  fibrous  capsule  has  been  split.  The 
resulting  wounds  are  best  closed  by  deep  catgut  sutures. 
The  after-treatment  is  the  same  as  after  any  other  suprapubic 
cystotomy. 

If  lobes  are  encountered  which  protrude  into  the  bladder 
and  are  pedunculated,  they  are  amputated  with  their  pedicles 
and  their  pedicle-stumps  ligated.  If  lobes  protruding  into  the 
bladder  exist,  whose  connection  with  the  bladder  floor  is  on  a 
large  basis,  mucous  membrane  and  capsule  may  be  split  and 
the  inclosed  prostatic  lobes  may  be  shelled  out.  The  super- 
fluous part  of  the  resulting  flaps  may  be  resected  and  the 
whole  seat  of  the  tumor  is  after  that  closed  with  deep  catgut 
sutures.  Suprapubic  prostatectomy  is  losing  more  and  more 
ground  in  comparison  with  the  perineal  prostatectomy,  on 
account  of  its  greater  mortality.  Suprapubic  prostatectomy, 
however,  is  the  proper  method  for  the  removal  of  pedunculated 
lobes  and  large  lobes  which  have  grown  into  the  viscus. 
Occasionally  the  operations  are  combined  in  selected  cases. 

There  is  another  method  of  treatment  for  these  cases  of 
hypertrophy,  with  the  object  of  decreasing  the  size  of  the 
hypertrophied  lobes — namely — 

Castration  and  resection  of  the  vasse  deferentise  are  performed, 
and  are  called  the  "  sexual  operations."  Besides  this,  organo- 
therapy has  also  been  used.  Ligation  of  the  arteries  and  the 
nerves  leading  to  the  prostate  has  likewise  been  carried  out. 
All  these  procedures  have  been  done  on  certain  theoretical 
grounds.  It  can  be  stated  positively  that  but  few  authentic 
cases,  wherein  permanently  good  results  have  been  seen,  are 
recorded.  All  these  methods  are  practically  becoming  obso- 
lete. Of  late,  the  perineal  prostatectomy  seems  to  be  the 
operation  in  most  favor. 

Neoplasms  of  the  Prostate. 
Varieties. — They  are  either  malignant  growths,  as  sarcoma 
or  carcinoma,  or  benign  tumors,  as  fibromata  or  fibrorayomata. 


TUBERCULOSIS  OF  THE  PROSTATE.  153 

Symptoms. — The  latter  is  that  which  is  often  described 
under  the  name  of  hypertrophy.  These  fibromata  represent 
tumors  which  may  till  almost  the  entire  bladder  cavity. 
They  can  be  palpated  by  bimanual  palpation,  and  cause  all 
forms  of  urinary  disturbances,  as  temporary  obstruction, 
residual  urine,  and  permanent  desire  for  urinating ;  their 
only  cure  consists  in  extirpation. 

Malignant  tumors  of  the  prostate  characterize  themselves 
by  a  rather  rapid  progression  of  the  prostatic  enlargement,  by 
the  extreme  hardness  of  the  nodules  embedded  in  the  prostate, 
and  lightning  pains  throughout  the  pelvis.  Very  soon  a 
general  cachexia  and  regionary  swelling  of  the  lymphatic 
glands  set  in.  In  consequence,  the  enlargement  of  the  pros- 
tate will  cause  the  known  symptoms  of  this  condition.  Occa- 
sionally a  very  severe  hemorrhage  might  occur  on  account  of 
an  artery  being  eroded  by  the  cancer.  These  tumors  may  be 
primary  in  the  prostate,  or  secondary  from  one  of  the  adjacent 
organs. 

Treatment. — A  radical  therapy  {extirpation)  is  as  a  rule  not 
feasible,  so  that  it  is  necessary  to  resort  to  symptomatic 
measures — administration  of  narcotics  for  the  pain,  and  in- 
strumentally  relieving  the  urinary  obstruction,  in  extreme 
cases,  by  establishing  a  permanent  suprapubic  fistula.  If 
the  urine,  on  account  of  ulcerations  of  the  neoplasms,  becomes 
decomposed,  cauterization  and  antiseptic  washings  of  the  blad- 
der should  be  practised. 

Tuberculosis  of  the  Prostate. 

Symptoms. — Tuberculosis  of  the  prostate  produces,  first  of 
all,  the  symptoms  of  inflammation,  enlargement,  softening  in 
spots,  and  soreness.  These  conditions  do  not  yield  to  any 
treatment,  thus  giving  rise  to  the  suspicion  of  a  specific  process. 
As  a  rule,  this  tuberculosis  is  combined  with  tuberculosis  of 
the  cords  and  with  tubercular  epididymitis.  In  the  course 
of  time  even  the  bladder  becomes  involved.  Frequent  pros- 
tatic hemorrhages  are  not  unusual. 

Treatment. — The  therapy  will  aim  at  an  improvement  of 


154     DISEASES  AND  TUMORS  OF  THE  PROSTATE  GLAND. 

the  general  health  by  nourishing  diet,  outdoor  exercise,  and 
the  administration  of  tonics.  Injections  of  iodoform  emul- 
sion into  the  parenchyma  may  be  tried.  In  appropriate  cases 
prostatectomy  may  be  resorted  to.  The  nsual  combination 
of  this  condition  with  tuberculosis  of  the  other  genitalia  makes 
the  prognostic  outlook  rather  unfavorable.  If  primary  in  the 
gland  and  if  remaining  localized,  operative  interference,  as 
excision,  ought  to  be  followed  by  good  results. 

Prostatic  Concretions. 

Pathology  and  Symptoms. — In  some  cases  retained  and  dried- 
up  secretions  of  the  prostatic  glands  give  rise  to  the  deposi- 
tion of  earthy  phosphates,  thus  forming  the  nuclei  of  calculi. 
These  calculi,  as  a  rule,  are  only  of  small  size,  but  in  rare 
cases,  by  permanent  deposition  of  phosphates,  they  may  attain 
considerable  size,  so  as  to  produce  a  manifest  enlargement  of 
the  prostate,  and  eventually  urinary  obstruction.  It  some- 
times happens  that  inflammation  and  suppuration  take  place 
around  the  concretions,  so  that  they  perforate  by  ulcerating 
into  the  rectum  or  into  the  urethra. 

Treatment. — If  the  stones  are  numerous  and  of  considerable 
size,  they  may  be  palpated,  and  if  they  cause  inconvenience, 
they  ought  to  be  removed  by  perineal  prostatotomy.  Occa- 
sionally they  may  be  felt  as  a  sound  is  passed  over  them,  or 
they  may  be  seen  through  a  urethroscope.  They  have  been 
removed  in  this  manner  when  small  in  size. 

Prostatic  Neurosis. 

Symptoms. — This  is  a  functional  disorder  due  either  to  a  gen- 
eral neurasthenia  or  to  neurotic  disturbances  which  are  con- 
fined to  the  prostate.  On  the  other  hand,  prostatic  neurosis 
mav  cause  general  neurasthenia,  which  subsides  after  the  local 
trouble  is  removed.  The  prostate  may  be  the  seat  of  typical 
neuralgias,  whose  attacks  come  on  without  special  irritation,  or 
the  prostate  is  the  seat  of  dull,  permanent  pain.  It  is  extremely 
sensitive  to  the  touch,  although  the  examination  fails  to  reveal 


PROSTATIC  NEUROSIS.  155 

any  anatomical  changes.  This  neurosis  quite  often  causes 
increased  desire  for  urinating.  Once  in  a  while  it  causes 
tenesmus  or  temporary  retention  through  spasms  of  the 
prostatic  sphincter.  If  the  patient  is  asleep  or  his  mind 
is  diverted  by  amusement  or  occupation,  all  the  symptoms 
will  subside.  The  urethra,  as  a  rule,  is  hypersensitive,  and 
although  no  inflammation  exists,  the  rectal  examination  is 
very  painful.  While  the  sexual  desire  is  quite  often  increased, 
the  sexual  power  is  diminished  or  entirely  gone.  The  patients, 
as  a  rule,  are  generally  depressed  and  apt  to  become  hypo- 
chondriacal. 

Treatment. — This  will  first  aim  at  the  improvement  of  the 
general  health  by  hydropathic  measures  and  through  the 
administration  of  tonics.  Often  we  achieve  quite  a  marked 
success  by  the  application  of  the  psychrophore.  This  is  a 
urethral  sound,  inside  of  which  a  leaden  hose  is  arranged 
in  such  a  way  that  cold  water  can  pass  through  it  after  the 
sound  is  inserted.  The  sittings  are  continued  for  five  or  ten 
minutes  and  repeated  at  regular  intervals  of  two  or  three 
days.  The  Faradic  current  may  also  be  used  to  good  advan- 
tage :  one  pole  is  inserted  into  the  rectum ;  the  other  is 
placed  on  the  abdomen.  Only  very  weak  currents  must  be 
used,  and  the  application  should  not  last  longer  than  two  or 
three  minutes.  Sexual  intercourse,  or  any  attempt  at  it,  is 
absolutely  to  be  avoided.  Massage  of  the  prostate  generally 
only  makes  matters  worse. 

QUESTIONS    OX    CONGENITAL    MALFOEMATIONS.    IN.TUEIES,  AND 
DISEASES  OF  THE  UEETHRA  AND  ADNEXA. 

Mention  the  more  common  malformations. 

What  are  the  most  common  malformations  ? 

What  is  meant  by  hypospadias  ? 

For  practical  purposes  what  divisions  are  made  of  this  malformation? 

What  is  the  treatment  ? 

Are  injuries  to  the  urethra  common  ? 

How  may  they  occur  ?    Where  are  they  most  usual  ? 

What  symptoms  may  they  cause  ? 

How  would  you  treat  this  condition  ? 

Do  tumors  of  the  urethra  ever  occur? 

What  are  the  more  common  varieties? 

How  would  you  treat  them  ? 

What  is  meant  by  urethritis? 


156     DISEASES  AND  TUMORS  OF  THE  PROSTATE  GLAND. 

In  what  manner  may  the  term  be  qualified  ? 

What  is  meant  by  gouorrhcea  ? 

What  is  meant  by  non-specific  urethritis  ? 

Do  tliey  run  a  similar  clinical  course '! 

May  urethritis  be  caused  by  any  other  distinct  germ  or  by  any  distinct  con- 
dition? 

What  do  you  know  about  the  gouococcus? 

In  the  case  of  gonorrhoea  is  there  a  distinct  period  of  incubation? 

What  would  the  requirements  be  for  a  remedy  to  be  used  as  an  abortive 
agent? 

What  is  used  for  this  purpose  ? 

What  may  result  from  their  use? 

What  is  understood  by  the  prophylactic  treatment  ? 

In  what  ways  may  gouorrhcea  be  acquired? 

What  causes  the  inflammatory  reaction  in  the  case  of  gonorrhoea? 

Describe  the  course  of  infection. 

When  the  discharge  is  at  the  maximum  are  thegonococci  in  great  number? 

What  are  the  symptoms  of  acute  anterior  gonorrhoea? 

From  what  should  acute  anterior  gonorrhoea  be  differentiated? 

Describe  the  manner  of  examining  the  discharge. 

Describe  the  Gram  stain. 

Describe  the  appearance  of  the  gonococcus. 

In  the  treatment  of  acute  anterior  gonorrhoea,  what  are  the  factors  to  be 
considered  ? 

What  does  the  hygienic  management  of  such  a  case  require? 

Describe  the  internal  treatment  of  such  a  case. 

In  what  manner  does  sandalwood  oil  act  favorably  ? 

When  would  you  prescribe  balsam  of  copaiba,  oil  of  cubebs,  and  the  uri- 
nary antiseptics?     Enumerate  combinations  of  these. 

When  is  it  ad\isable  to  use  an  opiate  or  a  sedative  in  these  cases? 

When  is  it  advisable  to  commence  the  local  treatment? 

Mention  the  newer  silver  salts. 

In  prescribing  agents  for  injections,  must  the  action  of  each  remedy  be  con- 
sidered? Why?  Mention  the  classes  and  enumerate  those  remedies  belonging 
to  each. 

Enumerate  the  difi'erent  modes  of  application. 

What  is  Neisser's  plan  for  using  the  silver  salts? 

How  would  you  commence  treatment  with  any  one  of  them  ?  Describe  in 
detail. 

When  and  how  would  you  use  the  antiseptic  and  slightly  astringent  group? 
When  the  astringents? 

What  is  meant  by  the  irrigation  method  ?  Describe  the  manner  of  giving 
an  irrigation.    Can  irrigations  also  be  given  with  the  aid  of  a  catheter  ?   How? 

What  is  meant  by  posterior  urethritis? 

Is  it  to  be  regarded  as  a  complication  of  anterior  urethritis?    Why? 

What  are  the  causes  for  this  complication  ? 

Describe  the  forms  in  which  it  manifests  itself. 

How  would  you  treat  the  condition  ? 

What  is  the  method  of  Janet,  of  Diday? 

What  is  understood  by  the  prophylactic  treatment  for  posterior  urethritis? 
Describe  in  detail. 

If  an  acute  posterior  urethritis  sets  in  during  the  treatment  of  an  anterior 
urethritis,  is  all  local  treatment  to  be  stopped  ?     Why  ? 

What  is  the  internal  treatment  and  with  what  objects  is  it  continued? 


QUESTIONS.   .  157 

What  is  a  chronic  anterior  urethritis  usually  due  to? 

What  parts  of  the  urethra  become  involved  ? 

What  is  the  classification  of  Finger? 

What  are  the  symptoms  ? 

Of  what  value  is  the  diagnostic  sound  in  these  cases?    The  urethroscope? 

What  is  understood  by  a  chronic  posterior  urethritis  ?  Does  a  prostatitis 
always  accompany  this  condition  ? 

Is  the  membranous  urethra  involved  more  than  the  prostatic  urethra  in 
these  cases  ? 

How  do  you  differentiate  from  a  chronic  anterior  urethritis  ? 

In  these  cases,  what  does  the  examination  by  the  method  of  Jadassohn 
show? 

On  what  does  the  treatment  of  these  cases  depend  ?    Give  in  detail. 

What  is  the  internal  treatment  ? 

What  should  the  local  treatment  be  ? 

Should  the  meatus  be  enlarged  so  that  sounds  may  be  passed  ?  If  infiltra- 
tions are  present,  how  are  they  to  be  treated?  What  type  of  sounds  should 
be  used?  In  treating  these  cases  is  there  a  guide  by  which  the  local  treat- 
ment is  to  a  certain  extent  regulated  ?    Give  in  detail. 

Is  the  posterior  urethra  treated  in  the  same  manner  as  the  anterior  urethra? 

Give  a  general  outline  of  treatment  if  one  or  both  parts  of  the  urethra  are 
involved. 

Has  the  urethroscope  any  advantage  in  the  mode  of  treatment  in  these 
cases  ?    if  so,  what  are  they  ? 

Enumerate  the  salts  and  their  strength  used  for  instillations,  and  give  their 
action. 

What  do  you  know  about  gonorrhceal  urethritis  in  the  female  ?  What  is 
the  treatment  ? 

What  is  a  stricture  ? 

Name  the  different  kinds  of  strictures  ? 

What  is  a  spasmodic  stricture  ?     How  may  they  be  accounted  for? 

What  is  meant  by  an  organic  stricture? 

In  what  different  forms  may  they  occur  ? 

What  are  inflammatory  strictures  ?    Describe  their  pathology. 

Is  there  a  limit  to  the  number  of  strictures  which  may  appear  in  any  single 
case? 

What  is  meant  by  a  soft  stricture  ?    a  hard  stricture?    an  elastic  stricture  ? 

What  are  the  symptoms  of  stricture  ? 

In  extreme  cases  do  the  symptoms  differ  ? 

What  are  the  pathological  changes  back  of  the  stricture — that  is,  in  the 
urethra  and  higher  urinary  organs? 

May  a  stricture  affect  the  passage  of  semen ?    in  what  manner? 

Does  a  stricture  ever  cause  retention  of  urine?  In  what  manner  may  this 
condition  be  treated  ? 

Do  fistulse  ever  occur  due  to  stricture  ?    How  are  they  accounted  for  ? 

What  is  urinary  infiltration  ? 

What  is  the  proper  mode  of  exploring  the  urethra  in  order  to  diagnose  a 
stricture  ? 

What  is  meant  by  a  sound  being  "  engaged  "  ? 

Explain  why  an  olive-tipped  sound  is  best  for  diagnostic  purposes. 

When  would  you  advise  meatotomy  ? 

How  is  it  possible  to  increase  the  length  of  the  frsennlum  by  a  simple 
operation  ?     Describe  it. 

What  is  the  Otis  urethrometer  ?    How  is  it  to  be  used  ? 


158     DISEASES  AND  TUMORS  OF  THE  PROSTATE  GLAND. 

WTiat  does  the  treatment  of  strictures  consist  of?  On  what  does  the  choice 
of  instruments  depend  ?  What  is  the  mode  of  procedure  when  using  sounds  ? 
When  does  it  become  necessary  to  use  dilators  ? 

In  what  class  of  cases  are  filiform  bougies  used,  and  how  are  they  to  be 
used  ?  Is  such  a  bougie  ever  left  in  place  for  twenty-four  hours?  With  what 
object  in  view? 

Can  the  entrance  of  a  stricture  ever  be  found  with  the  aid  of  a  urethroscope  ? 

In  what  class  of  cases  are  bougies  to  be  used  ? 

What  is  a  La  Fort  sound  ?     Describe  it  and  its  use. 

With  what  regularity  are  sounds  passed  ? 

If  passing  of  sounds'causes  urethral  fever  each  time,  what  is  to  be  done? 

What  are  the  cutting  operations?     What  are  they  called? 

With  what  kind  of  instrument  is  an  internal  urethrotomy  done? 

Describe  the  most  typical  instrument.  Describe  in  detail  the  different 
steps  of  such  an  operation. 

Can  any  complications  arise  ?     How  are  they  treated  ? 

What  is  meant  by  an  external  urethrotomy?  How  is  it  performed ?  de- 
scribe in  detail. 

In  what  cases  should  perineal  drainage  be  instituted?  WTien  should  a 
permanent  catheter  be  used?     How  long  are  these  to  remain  in  place? 

In  what  cases  does  it  become  imperative  to  perform  a  suprapubic  cystotomy? 

Are  internal  and  external  urethrotomies  made  in  the  same  case  ?  What 
are  the  indications  for  the  former?  for  the  latter? 

What  is  meant  by  the  electrolytic  mode  of  treatment  of  strictures? 

Why  is  this  method  condemned  ? 

Why  should  the  method  of  divulsion  not  be  used  ? 

What  is  meant  by  rapid  dilatation?     How  is  it  carried  out? 

What  is  meant  by  progressive  dilatation  ? 

Give  a  resume  of  all  the  modes  of  treatment  of  the  different  varieties  of 
stricture  ? 

Enumerate  other  complications  of  urethritis. 

Of  what  is  oedema  of  tbe  foreskin  often  indicative? 

How  would  you  treat  the  condition  ? 

Are  the  urethral  follicles  ever  involved? 

What  is  meant  by  peri-urethral  inflammation  ?  Are  such  inflammations 
ever  the  cause  of  fistula?  What  is  their  treatment?  In  what  manner  must 
they  be  surgically  treated  ? 

Are  Cowper's  glands  ever  affected?  In  what  manner?  How  would  you 
diagnose  this  condition?  What  is  the  treatment?  How  would  you  treat  a 
peri-Cowperitis  and  a  chronic  Cowperitis  ? 

What  is  meant  by  a  spermato-cystitis  ?  Is  this  condition  often  accompanied 
by  other  complications  of  urethritis  ?  What  are  the  symptoms  ?  How  is  the 
diagnosis  made  ?    What  is  the  treatment? 

What  is  meant  by  "  stripping  "  the  seminal  vesicles? 

What  is  the  prostate  gland  ? 

What  is  meant  by  the  prostatic  urethra? 

What  is  the  function  of  the  prostate  gland  ? 

Wliat  forms  of  prostatitis  are  there  ?  What  are  the  the  symptoms  ?  How 
would  you  diagnose  and  what  is  the  treatment  of  acute  prostatitis  of  the 
entire  gland?  Of  acute  follicular  prostatitis?  Of  parenchymatoas  prosta- 
titis?    Of  abscess  of  the  prostate  gland  ? 

When  would  you  advise  operation  upon  a  prostatic  abscess?    Why? 

Describe  Zuckerkandl's  incision  for  reaching  the  prostate  gland. 


CONGENITAL   ANOMALIES.  159 

What  are  the  symptoms,  how  would  you  diagnose,  and  what  is  the  treat- 
ment for  chronic  prostatitis? 

How  would  you  make  the  dififerential  diagnosis  between  acute  posterior 
urethritis  and  acute  prostatitis  ? 

What  is  meant  by  prostatic  hypertrophy  ?  In  what  different  ways  may 
this  occur?  How  is  the  diagnosis  made?  Is  it  readily  made  in  every  case? 
What  are  the  diagnostic  points  of  prostatic  enlargement?  What  are  the  symp- 
toms? What  are  the  results  if  the  condition  is  left  alone?  What  does  the 
treatment  consist  of  ? 

What  is  meant  by  "catheter  life " ? 

When  obliged  to  catheterize  a  patient  ,with  prostatic  hypertrophy,  what  is 
the  correct  mode  of  procedure  ? 

Is  it  ever  advisable  to  make  a  suprapubic  fistula  ? 

When  is  it  advisable  to  make  a  prostatotomy  ?    A  prostatectomy  ? 

Describe  the  Bottini  instrument  and  the  Bottini  operation. 

Describe  the  indications  for  the  different  prostatectomy  operations.  De- 
scribe the  operations.     Are  they  ever  combined  and  why? 

What  is  meant  by  the  "  sexual  operations  "  ?     What  are  they  ? 

What  is  meant  by  the  organotherapy  of  these  cases? 

Mention  the  more  common  neoplasms  of  the  prostate  gland.  As  a  rule, 
what  symptoms  do  they  cause  and  how  are  they  diagnosed  ? 

How  do  malignant  growths  of  the  prostate  gland  characterize  themselves? 

If  they  cannot  be  operated  on,  in  what  manner  should  they  be  treated  ? 

What  is  meant  by  tuberculosis  of  the  prostate  gland  ?  What  are  the  symp- 
toms ? 

How  would  you  treat  this  condition  ? 

Is  it  best  to  operate  ?    If  so,  when  ? 

What  are  prostatic  stones  ? 

How  can  you  account  for  them  ? 

What  complications  may  arise  from  them  ?    How  are  they  treated  ? 

What  is  meant  by  a  prostatic  neurosis? 

How  is  it  possible  to  make  such  a  diagnosis? 

How  would  you  treat  these  cases  ? 

ANOMALIES,  INJURIES,  AND  DISEASES  OF  THE 
SCROTUM,  OF  THE  TESTICLES  AND  THEIR 
COVERINGS,   AND   OF    THE    CORDS. 

CONGENITAL  ANOMALIES. 
Retention  of  the  Testicle. 

Etiology,  Varieties. — During  the  embryological  development 
many  anomalies  involving  both  the  internal  and  the  external 
genitalia  may  arise.  There  may  be  an  absence  of  one  or  of 
both  testicles.  Whenever  a  testicle,  instead  of  descending 
into  the  scrotum  before  birth, — although  it  may  do  so  in  the 
following  years, — remains  in  the  abdominal  cavity  back  of 
the  peritoneum   or  in  some  part  of  the  inguinal  canal  before 


160  CONGENITAL  ANOMALIES. 

it  reaches  the  scrotum  ;  being  fixed  permanently  or  tempo- 
rarily there,  it  is  referred  to  as  a  "  retentio  testis"  ;  if  in  the 
inguinal  canal,  as  "  retentio  testis  inguinalis  "  ;  if  in  the  ab- 
dominal cavity,  "  retentio  testis  abdominaUs."  If  but  one 
testicle  remains  in  the  abdomen,  it  is  referred  to  as  "  monor- 
chismus  "  ;  if  both,  "  cryptorchismus"  In  the  latter  case  the 
other  genitalia  are  normally  developed  and  the  bearer  may 
be  virile.  In  those  cases  where  the  external  genitalia  are 
undeveloped  and  where  there  is  absence  of  semen,  in  addi- 
tion to  cryptorchismus  it  is  referred  to  as  "  anorchismus." 

Diagnosis. — This  condition  is  diagnosed  by  the  absence  of 
the   organ  from  its  normal  situation. 

Symptoms. — If  it  is  retained  in  the  inguinal  canal,  we  find 
above  the  pubic  tubercle  a  smooth,  soft,  small,  egg-shaped 
tumor,  which  reacts  on  pressure  with  characteristic  sensa- 
tions to  the  patient  of  tenderness,  faintness,  weakness,  or 
nausea.  Occasionally  congenital  hydrocele  and  even  hernias 
are  present,  with  or  without  the  presence  of  the  testicle.  In 
cases  of  monorchismus  the  testicle  is  usually  atrophied,  and 
therefore  if  complicated  with  the  foregoing  signs  is  difficult 
to  palpate.  In  cryptorchismus  the  testicles  can  rarely  be  felt, 
and  in  these  cases  are  in  the  abdominal  cavity.  If  the  testicle 
remains  for  a  long  time  in  the  inguinal  canal,  its  development 
may  be  impaired  in  varying  degrees.  It  is  a  well-established 
fact  that  retained  testicles  incline  to  malignant  degeneration. 

Treatment. — Manipulations  are  begun  in  early  life  which 
tend  to  pull  down  the  organ  into  the  scrotum.  In  some  cases 
descensus  of  the  retained  testicle  into  the  scrotum  takes  place 
when  puberty  is  reached.  If  this  should  not  happen  and 
should  manipulations  not  succeed,  the  testicle  is  to  be  brought 
down  by  operative  interference.  The  operation  is  to  cut 
down  to  the  tumor  in  the  inguinal  canal  and  free  the  sper- 
matic cord,  high  up,  by  blunt  dissection.  In  cases  of  neces- 
sity the  Bassini  operation  is  performed  at  the  same  time. 
The  testicle  is  brought  down  into  the  scrotum  and  its  tunica, 
and  the  sheath  of  the  spermatic  cord  fastened  by  a  few 
stitches.  The  operation  is  called  orchidopexy.  If  it  should 
be  impossible  to  bring  the  testicle  down,  and  if  it    should 


ACQUIRED  DISEASES.  161 

cause  great  inconvenience,  or  if  malignant  degeneration  should 
take  place,  castration  must  be  resorted  to.  However,  castra- 
tion must  be  done  only  as  a  last  resort,  and  never  during  the 
period  of  puberty  if  it  can  be  avoided. 

Other  Testicular  Abnormalities. 

There  are  other  conditions,  as  abnormal  niohility,  inversin 
testis,  both  on  the  horizontal  and  vertical  axes,  and  abnormal 
locations,  which  cause  disturbances. 

The  symptoms  of  invertio  testis  or  torsion  depend  upon 
acute  inflammatory  processes  of  these  parts  :  sudden  pain, 
followed  by  swelling  of  testicles  and  epididymis,  dizziness, 
faintness,  nausea,  and  vomiting.  Even  hemorrhages  and 
discoloration  of  the  parts  may  occur  in  extreme  cases.  It  is 
necessary  to  differentiate  these  cases  from  incarcerated  hernia. 

Ectopia  testis  is  the  abnormal  location  of  a  testicle.  Its 
normal  situs  it  neither  attains  before  nor  after  birth  in  such 
cases.  Ectopia  crurali.s,  perinealis,  scroto-femoralis,  are  terms 
explaining  their  locations.  In  all  cases  of  abnormal  descensus 
inflammatory  processes  easily  occur  and  malignant  tumors 
also  arise. 

ACQUIRED  DISEASES. 

Injuries  and  Diseases  of  the  Scrotum. 

Contusions  of  the  scrotum  are  not  uncommon,  and  subcuta- 
neous hemorrhages  readily  occur.  Usually  there  is  rapid 
absorption,  but  once  in  a  while  the  hemorrhage  remains  cir- 
cumscribed— hcematoma  scroti.  In  these  cases  the  hemorrhage 
is  between  the  tunicse  dartos  and  communis.  Aspiration  or 
incision  under  aseptic  precautions  should  be  advised.  Usually 
all  incised  wounds  heal  rapidly. 

Inflammatory  processes  of  the  scrotum  are  not  usual — -eczema, 
erysipelas,  phlegmons,  gangrene,  are  all  met  with,  and  must 
be  treated  as  when  they  occur  elsewhere  on  the  body. 

Neoplasms  of  the  Scrotum, — Here  elephantiasis,  rather 
uncommon  in  this  country,  must  be  differentiated  from  an 
ordinary  oedema  of  the  scrotum,  which  is  frequently  seen   in 

II— V.  D. 


162  INJURIES  TO   THE   COVERINGS. 

connection  with  kidney  and  heart  diseases.  This  elephantiasis 
scroti  consists  of  a  thickening  of  the  scrotal  cutis  and  sub- 
cutaneous tissue,  and  cell  infiltration  about  and  in  the  vessel- 
walls  themselves.  The  lymph-vessels  are  usually  enormously 
dilated,  and  the  glands  are  enlarged. 

True  tumors  of  the  scrotum  are  also  met  with  :  atheromata 
are  common  ;  dermoids  occasional ;  lipoma  and  sarcoma  but 
rare.  Carcinoma  scroti  is  met  with  in  individuals  handhng 
coal-tar  products.  Usually  chronic  inflammatory  processes 
of  the  skin  exist  previous  to  any  carcinomatous  changes,  but 
prior  to  this  warty  excrescences  with  a  hard  base,  excoriated 
and  ragged  surface,  secreting  a  serous  fluid,  and  apparently 
metastatic  growths  in  the  scrotum,  appear.  If  recognized 
sujEficiently  early,  the  prognosis  is  fair.  A  radical  operation, 
including  the  removal  of  the  inguinal  glands,  gives  good 
results. 

DISEASES  OF  THE  COVERINGS  OF  THE  TESTICLES 
AND  CORDS. 

Injuries  to  the  Coverings. 

Hemorrhages  into  the  loose  connective  tissue  between  the 
coverings  of  either  cord  or  testicles  are  met  with.  The  hsem- 
atoma  about  the  cords  may  reach  fairly  large  dimensions, 
while  those  about  the  testicles  are  comparatively  small  and 
circumscribed.  However,  these  may  be  found  together,  and 
the  tumor-mass  may  reach  large  dimensions.  Arising  fairly 
suddenly  after  injury,  spontaneous  pain  as  well  as  tenderness 
along  tlie  cord  and  testicle  may  occur,  and  if  the  hemorrhage 
reaches  the  internal  ring,  may  be  mistaken  for  incarcerated 
hernia.  These  hemorrhages  are  without  the  serous  space, 
although  hemorrhages  occurring  within  the  tunica  vaginalis 
propria  are  also  seen.  In  these  cases  the  blood  remains  fluid 
lone:er  than  in  the  previous  cases.  The  prognosis  is  not  so 
good,  as  the  absorption  cannot  occur  so  readily.  Consequently, 
in  the  intravaginal  hfematoma  it  is  best,  under  aseptic  precau- 
tions, to  evacuate  with  a  trocar  in  order  to  prevent  hydrocele 


INFLAMMATORY  DISEASES   OF  THE  COVERINGS.    163 

and  chronic  inflammatory  conditions.  In  both  classes  of 
cases  the  patient  should  be  put  to  bed,  the  parts  elevated, 
and  an  ice-bag  placed  on  the  swelling. 

Inflammatory  Diseases  of  the  Coverings. 

Acute  inflammatory  conditions  of  the  coverings  of  the  testi- 
cles {hydrocele  vaginalis  acuta)  or  of  the  cords  [hydrocele  acuta 
funiculi  spermatici)  are  noticed  after  injuries  to  these  parts 
and  in  acute  infectious  diseases  ;  occur  suddenly,  with  all  the 
signs  of  inflammation  and  cedema  of  the  skin ;  occasionally, 
this  may  pass  into  suppuration.  The  treatment  consists  of 
rest  in  bed ;  elevation  of  the  parts  ;  at  first  ice-packs  ;  later, 
warm  moist  antiseptic  applications,  frequently  changed.  If 
no  relief,  aspiration ;  if  suppuration,  incision  and  drainage. 

Chronic  Inflammatory  Diseases  of  the  Coverings. — The 
chronic  inflammation  of  the  tunica  vaginalis  propria  testis 
occurs  on  one  or  both  sides,  visceral  and  parietal,  and  is  an 
exceedingly  common  condition.  It  occurs  most  frequently 
between  the  ages  of  fifteen  and  thirty  years. 

Hydrocele. 

Definition. — This  is  the  accumulation  of  serous  fluid  within 
the  sac  of  the  tunica  vaginalis. 

Etiology. — Hydrocele  arises  frequently  without  any  apparent 
cause,  and  authorities  without  number  insist  that  there  is  no 
evidence  of  any  inflammatory  disease  either  in  the  serous 
exudate  or  in  the  adjoining  coverings.  However,  statistics 
show  that  traumatism  takes  part  in  a  large  number  of  cases, 
and  that  gonorrhoea  exerts  a  great  influence  in  this  direction 
and  must  be  regarded  as  an  important  cause.  Other  local 
conditions,  as  tumors,  are  often  associated  with  it,  and, 
besides,  it  is  frequently  found  to  be  present  at  time  of  birth. 

Varieties. — It  is  obligatory  to  distinguish  between  hydro- 
cele testis — that  is,  if  the  exudate  is  confined  to  the  testicular 
part  of  the  tunica,  while  the  tunica  higher  up  is  obliterated ; 
then  hydrocele  funicularis,  if  the  testicular  tunica  has  oblit- 
erated,  while   the   funicular   part    has   remained    open — and 


164  HYDROCELE, 

hydrocele  communis,  if  the  exudate  extends  along  the  testicular 
and  funicular  space  of  the  tunica ;  and,  finally,  hydrocele 
communicans,  or  congenital  hydrocele,  if  the  entire  processus 
vaginalis  has  remained  open,  so  that  its  space  communicates 
with  the  free  peritoneal  cavity.  Hydrocele  bilocularis  consists 
of  two  sacs :  one  intra-abdominal  and  the  other  extra-abdom- 
inal, communicating  with  each  other.  Hydrocele  multilocularis 
consists  of  numerous  cystic  inclosures  of  exudates  situated 
anywhere  along  the  cord  or  testis. 

Symptoms. — Hydrocele  communis  shows  such  characteristic 
symptoms  that  it  can  scarcely  be  mistaken  for  anything  else ; 
it  usually  develops  slowly,  without  any  pain  or  symptom,  but 
is  first  noticeable  on  account  of  size  and  weight,  which  com- 
mences to  drag  on  the  adherent  parts  and  thereby  causes  pain. 
The  surface  of  the  tumor  is  smooth,  more  or  less  tense,  movable 
within  the  scrotum,  and  the  overlying  skin  is  tense  and  often- 
times shows  dilated  veins  ;  the  whole  mass  fluctuates.  In  the 
large  majority  of  cases  the  testes  and  epididymis  protrude  into 
the  fluid  and  can  be  palpated  if  the  amount  of  fluid  is  not  too 
large.  There  is  a  transparency  to  these  cases  that  is  almost 
positive.  A  tube  should  be  held  tightly  against  the  tense 
skin,  a  light  to  the  opposite  side  of  the  swelling,  and  then, 
by  looking  through  the  tube  toward  the  source  of  light  {best 
in  a  darkened  room),  the  translucency  can  be  noted.  If  in- 
volving the  tunica  about  the  testis,  the  hydrocele  is  egg-  or  pear- 
shaped  ;  if  involving  the  tunica  about  the  cord,  most  often  small 
and  spherical.  In  the  case  of  hydrocele  communicans  all  the 
fluid  in  the  sac  can  easily  be  made  to  pass  into  the  abdominal 
cavity,  or  itself  readily  passes  into  this  latter-named  cavity  ; 
and,  again,  this  fluid  can  be  demonstrated  to  be  free  by  placing 
the  patient  in  different  positions.  If  this  cannot  be  shown,  it 
must  be  a  hydrocele  bilocidaris.  In  both  cases  the  sac  about 
the  testis  fills  up  when  the  patient  stands  up  or  coughs. 
Hydrocele  may  affect  the  condition  of  a  patient.  If  large, 
it  may  prevent  manual  labor ;  cause  disturbance  in  uri- 
nation ;  and  give  rise  to  diseases  of  the  scrotum,  such  as 
eczema. 

Treatment. — In  children,  hydroceles  have  disappeared  spon- 


2"  to  1  gramme  carbolic  acid^  with  sufficient  glycerine  to 


HYDROCELE.  165 

taneously,  but  this  is  rare.  In  congenital  hydrocele  the  care- 
ful application  of  a  truss  has,  by  causing  the  obliteration  of 
the  processus  vaginalis,  given  good  results.  The  most  simple 
j)rocedure,  both  in  children  and  in  adults,  is  aspiration  of  the 
fluid  with  the  aid  of  a  trocar.  After  all  aseptic  precautions 
the  tumor  is  grasped  from  behind,  the  skin  of  the  anterior 
surface  is  held  tense,  and  noting  that  the  testicle  is  to  the 
posterior  part  of  the  swelling,  the  trocar  is,  with  a  sudden 
move,  thrust  into  the  cavity  in  such  a  manner  that  the  point 
does  not  pass  through  a  vein  of  the  skin  or  does  not  reach 
the  testicle  or  the  epididymis.  The  fluid  is  withdrawn.  If 
the  hydrocele  persistently  recurs,  the  procedure  should  be 
repeated,  and  one  of  the  following  fluids  injected  : 

2  to  10  c.c.  tincture  of  iodine. 

1 

2 

keep  it  fluid 

5  to  10  c.c.  absolute  alcohol. 

As  the  canula  is  withdrawn  the  -parts  should  he  massaged, 
so  that  the  irritating  fluids  may  reach  all  parts  of  the  tunica. 
Iodine  is  very  apt  to  be  absorbed  from  the  tunica,  and  has 
thus  caused  fatal  poisoning.  Carbolic  acid  closes  the  mouths 
of  the  lymphatics  more  readily  and  is  not  absorbed.  Never- 
theless, massage  had  best  be  done  with  the  canula  in  situ  and 
then  the  excess  of  fluid  evacuated.  Usually  severe  pains  set 
in  about  these  parts ;  swelling  and  temperature  occur.  In 
five  to  seven  days  usually  all  has  passed  over. 

There  are  operative  procedures  which  give  more  positive 
results.  Opening,  with  a  longitudinal  incision,  and  irrigating 
the  cavity  between  the  layers  of  the  tunica  with  a  5  per  cent, 
carbolic  acid  solution  ;  suturing  tunica  vaginalis  to  integu- 
ment, and  packing  cavity  with  gauze  and  dressing  aseptically 
is  Volkmann's  operation.  Von  Bergmann  advised  a  still  more 
radical  operation,  in  that  the  tunica  vaginalis  up  to  attachment 
of  epididymis  is  extirpated  and  testicle  dropped  back  into  the 
scrotum  and  all  hemorrhage  carefully  stopped  and  the  skin 
then  brought  together. 

Any  form  of  hydrocele  may  become  infected.  Naturally, 
if  it  is  a  congenital  hydrocele,  fatal  results  may  follow.     The 


166  HEMATOCELE—  VARICOCELE. 

others  have  a  variable  course.     All  must  be  treated  surgically 
as  soon  as  possible. 

Haematocele. 

Definition  and  Pathology. — This  is  regarded  as  a  chronic 
inflammatory  process  due  to  traumatism  or  spontaneous  hem- 
orrhage, characterized  histologically  by  the  formation  of 
connective  tissue  in  the  tunica  vaginalis,  and  by  hemorrhages 
into  the  wall  and  upon  the  surface.  Consequently,  the  con- 
tents of  such  a  condition,  since  the  wall  of  the  cavity  may 
often  be  1  to  2  cm.  thick,  vary,  and  may  be  hemorrhagic, 
serous,  or  serofibrinous. 

Etiology  and  Symptoms. — Most  often  a  hemorrhage  follows 
immediately  after  a  traumatism,  and  the  tumor  in  the  scrotum 
is  at  once  noticeable,  or  the  swelling  first  arises  in  the  course 
of  weeks  or  months.  In  the  course  of  time  pressure  and 
pain  develop.  Fluctuation  is  not  so  readily  elicited  as  in 
hydrocele ;  its  consistency  is  usually  harder,  varies  in  dif- 
erent  places,  and  is  not  transparent. 

Prognosis  and  Treatment. — On  account  of  the  thickening  of 
the  tunica,  in  every  case  the  sooner  the  condition  is  surgically 
treated,  the  better  are  the  results.  Longitudinal  incision 
and  removal  of  the  thickened  walls  will  be  enough,  as  a  rule. 
In  other  cases  castration  may  become  necessary. 

Varicocele. 

Definition. — This  is  regarded  as  an  abnormal  dilatation  and 
lengthening  of  the  veins  of  the  pampiniform  plexus  and  of 
the  veins  of  the  spermatic  cord. 

Etiology. — It  is  an  exceedingly  common  condition,  and 
occurs  most  frequently  about  the  age  of  puberty.  At  this 
time  statistics  show  that  25  cases  in  1000  is  about  the  ratio  ; 
again,  the  left  side  in  about  80  per  cent,  of  the  cases ;  right 
side  in  9  per  cent.;  and  on  both  sides  in  about  11  per  cent, 
of  the  cases.  The  left  side  is  more  often  affected  than  the 
right,  because  the  left  spermatic  vein  empties  into  the  left 
renal  vein  at  a  right  instead  of  an  oblique  angle,  has  rarely  a 


VARICOCELE.  167 

valve,  and  hence  has  all  the  disadvantages  possible  in  with- 
standing the  pressure  within  the  renal  vein,  which  is  higher 
than  in  any  other  veins  of  the  body.  In  individuals  who  are 
obliged  to  stand  a  great  deal  the  hydrostatic  pressure  appar- 
ently ap})ears  to  be  the  direct  cause.  Again,  there  seems  to 
be  a  predisposition  in  certain  individuals  with  large  scrotums 
and  exceedingly  thin-walled  veins.  In  many  cases  it  makes 
its  appearance  gradually,  and  in  others  suddenly,  after  trau- 
matism or  exertion.  Different  parts  of  the  veins  are  appar- 
ently more  affected  than  others.  The  veins  in  and  imme- 
diately about  the  testicles  are  most  often  involved,  although 
the  enlargement  may  reach  high  up  into  the  inguinal  canal. 

Symptoms. — The  history  most  often  shows  that  there  is 
practically  no  pain  in  their  development,  although  pains  may 
arise  after  excessive  exercise,  especially  during  the  heated 
season.  These  particular  pains  disappear  with  rest  in  the  hori- 
zontal position.  Occasionally  these  pains  are  of  a  dragging 
character,  or  even  shooting,  and  pass  upward  into  the  inguinal 
canal,  or  even  toward  the  lumbar  region.  They  may  be  of  a 
stinging  or  sharp  character,  noticeable  during  sexual  excite- 
ment. When  standing,  oftentimes  the  peculiar,  irregularly 
dilated  and  arranged  strands  appear  through  the  thin  skin 
of  the  scrotum,  and  in  the  light  forms  this  condition  disap- 
pears altogether  when  the  patient  assumes  a  horizontal  posi- 
tion. In  some  cases  hardened  plates  in  the  course  of  the 
veins  are  noticeable. 

Differential  Diagnosis. — Inguinal  hernia  and  hydrocele  com- 
municans  must  occasionally  be  distinguished  from  it.  The 
condition  rarely  improves  by  itself ;  it  remains  at  a  standstill 
by  care  not  to  overexert  or  absence  of  sexual  excitement, 
and  by  the  wearing  of  a  tight  and  comfortably  fitting  suspen- 
sory bandage. 

Treatment. — Whenever  the  venous  circulation  disturbs  the 
normal  condition  of  the  scrotal  skin,  as  these  veins  also 
enlarge,  allowing  readily  of  dermatoses,  or  when  the  pains 
become  severe  or  the  testicles  atrophy,  or  if  hypochondriasis 
sets  in,  one  or  all  the  indications  are  present  for  advising 
operative  interference.      Bandages  of  different  styles,  injec- 


168       INJURIES   OF  THE  TESTES  AND  EPIDIDYMIS. 

tions  of  alcohol  into  the  venous  convolutions,  and  subcu- 
taneous suturing,  which  was  formerly  practised  a  great  deal 
and  still  is  advised,  are  best  left  undone. 

If  an  operative  step  is  necessary,  an  open  operation  is 
most  advisable.  A  longitudinal  incision,  3  to  6  cm.  long,  is 
made  over  the  most  prominent  part  of  the  swelling,  dissec- 
tion into  the  tunica,  and  ligation  and  resection  of  the  vari- 
cosed  veins,  leaving  intact  the  vas  deferens,  artery,  and  suffi- 
cient veins  for  a  return  circulation,  and  then  apposition  of 
the  stumps  and  union  of  the  skin  in  the  usual  manner  are 
the  steps.  If  the  scrotum  is  very  long,  in  order  to  shorten 
it  the  incision  is  often  united  transversely.  Partial  amputa- 
tion of  the  scrotum  has  also  been  advised  in  these  cases. 

Injuries  of  the  Testes  and  Epididymis. 

Contusions  to  these  parts  are  not  uncommon.  The  scrotum 
usually,  however,  also  shows  signs.  The  testicles,  epididymis, 
or  both  become  enlarged,  sometimes  enormously  so,  and  ex- 
ceedingly painful.  With  patient  in  bed,  elevation  of  the 
part,  and  ice-cold  applications  there  is  usually  a  diminution 
of  the  swelling.     Anodynes  are  oftentimes  required. 

Dislocations  of  the  testicles — "  luxatio  testes'' — have  been 
noted ;  when  under  the  abdominal  wall,  they  are  called 
"  luxatio  abdominalis.''  In  recent  cases  the  testicle  can  be 
replaced  and  the  foregoing  treatment  instituted. 

Inflammation  of  the  Epididymis  (Epididymitis). 

Causes. — Inflammatory  processes  of  the  epididymis  are 
much  more  common  than  those  of  the  testes.  Both  may  be 
involved  at  the  same  time,  and  are  frequently  accompanied  by 
hydrocele.  Traumatism  may  cause  a  distinct  involvement  of 
the  epididymis,  and,  besides,  metastatic  inflammatory  proc- 
esses reaching  the  epididymis  by  way  of  the  circulation  occur. 
However,  the  most  common  epididymitis  is  the  one  due  to 
some  urethral  pathological  condition,  wherein  the  infection 
travels  along  the  vasa  deferentia,  reaching  the  epididymis  in 
this  way — epididymitis  urethrcdis. 


INFLAMMATION  OF  THE  EPIDIDYMIS.  169 

Acute  aud  chronic  inflammatory  processes  of  the  urethra — 
either  specific  or  non-specific  urethritis  ;  strictures ;  prostatic 
hypertrophy;  seminal  vesiculitis;  prostatitis;  traumatism 
caused  by  instrumental  examinations,  and  the  passage  of 
stones  or  fragments  of  stone  through  the  urethra  after 
litholapaxy ;  and  catheterization  and  instrumental  treatment 
of  the  urethra,  etc.,  where  germs  are  already  present — as  in 
aseptic  handling  bacteria  cannot  be  introduced. 

Symptoms. — Acute  swellings  of  the  epididymis  occur,  as  a 
rule,  after  such  causes.  In  as  high  as  5  to  10  per  cent,  of  all 
patients  suffering  from  urethritis  this  condition  arises  during 
some  time  of  its  course,  but  especially  during  the  second  or 
third  week  after  the  beginning  of  a  urethritis,  when  the  pos- 
terior urethra  becomes  involved,  and  appears  suddenly  with 
severe  pain  in  the  inguinal  region,  and  later  in  the  epididymis. 
Usually  but  one  side  is  involved,  probably  the  left  oftener 
than  the  right ;  both  may,  however,  be  inflamed  at  the  same 
time.  This  pain  may  reach  the  lumbar  region  or  it  may  pass 
down  the  thigh  on  the  side  affected,  but  concentrates  itself  in 
the  epididymis.  The  swelling  and  tenderness  generally  in- 
crease, so  that  in  the  course  of  from  three  to  five  days  the 
height  is  usually  reached.  At  this  time  the  tumor  may  be  the 
size  of  a  large  pea.  In  most  of  the  cases  the  epididymis  can  be 
felt  to  be  much  enlarged,  although  the  testes  proper  may  at  the 
same  time  not  be  aflPected.  Fever,  nausea,  and  even  vomiting 
and  restlessness  may  be  present.  At  times  symptoms  of  an 
acute  posterior  urethral  involvement  accompany  these.  The 
acute  pains  pass  away  in  about  from  ten  to  fifteen  days,  and 
the  swelling  of  the  epididymis  can  be  outlined  with  great  ease. 

An  inflammation  of  the  cord,  "  funiculitis,''  often  occurs  at 
the  same  time,  and  the  mass  which  extends  into  the  inguinal 
canal  can  readily  be  palpated,  although  often  associated  with 
great  tenderness. 

Treatment. — The  rational  management  necessitates  the  alle- 
viation of  the  cause.  During  the  course  of  instrumental 
treatment  it  is  often  advisable  to  stop  such  procedures,  although 
in  cases  of  retention  of  urine,  of  hypertrophy  of  the  prostate, 
or  even  in  acute  cystitis,  catheterization  must  be  persisted  in. 


170  INFLAMMATION  OF  THE  EPIDIDYMIS. 

In  all  cases  of  severity,  however,  the  patient  should  be  placed 
in  bed,  the  testicles  elevated,  not  allowing  them  to  drag  on 
the  cord.  This  can  be  done  by  placing  supports  between  the 
legs  or  by  the  aid  of  well-fitting  T-bandages.  In  the  incip- 
ient stages  ice-cold  applications,  frequently  changed,  are  of 
help,  but  after  the  swelling  has  existed  for  a  few  days  hot 
boric  acid  fomentations,  frequently  repeated,  will  give  quickest 
relief  and  cause  the  swelling  to  diminish  most  rapidly.  Abor- 
tive remedies,  such  as  blistering  the  scrotum  and  giving  wine 
of  antimony  internally,  have  been  abandoned.  The  applica- 
tion of  adhesive  plaster  in  the  early  stages  scarcely  warrants 
a  trial,  although  this  is  highly  recommended  and  still  advised. 
The  method  consists  of  applying  an  adhesive-plaster  strip 
above  the  swollen  testicle,  then  longitudinal  strips,  and  finally 
transverse  strips,  in  order  to  cause  compression.  In  most 
cases  considerable  pain  follows,  and  the  bandages  must  be 
removed.  This  process  must  be  repeated  frequently  in  order 
to  gain  any  result. 

If  in  the  course  of  a  urethritis  the  pain  is  not  too  severe,  the 
treatment  of  the  urethritis,  during  which  the  testicle  may 
have  become  swollen,  may  be  continued.  This  consists  of 
irrigations  according  to  the  method  of  either  Diday  or  Janet. 
In  all  cases  the  urine  should  be  rendered  as  bland  as  possible, 
erections  avoided,  and  frequent  urination  allayed. 

The  following  formulas  will  be  found  of  value : 

I^     Potassii  bromidi,  25.00  grammes ; 

Potassii  citratis,  15.00         " 

Codein,  phosphatis,  0.25  gramme  ; 

Tinct.  hyoscyami,  30.00  grammes  ; 

Elix.  simplicis,  30.00         " 

Aquse  camphor.,  q.  s.  ad  250.00         " 

M.  &  Sig. — One  tablespoonful  every  four  hours. 

Oftentimes  there  is  a  prostatitis  or  spermato-cystitis,  and 
these,  as  well  as  any  other  complication,  must  receive  atten- 
tion : 


INFLAMMATION  OF  THE  TESTES  AND  EPIDIDYMIS.   171 

^i     Ext.  hyoscyami,  0.30  gramme ; 

Morphin.  siilph.,  0.15         " 

Ichthyolis,  3.00  grammes ; 

Olei  theobrom.,  q.  s. 

M.    Ft.  in  sup.  rect.  No.  x. 

Sig. — Insert  one  suppository  every  eight  hours. 

In  the  acute  stages  sitz-baths,  depletion  of  the  pelvis,  and,  if 
hydrocele  persists,  applications  of  tincture  of  iodine  or  aspi- 
ration ;  internally  the  following  prescription  may  be  used  : 

^     Potassii  iodidi,  15.00  grammes  ; 

Potassii  citratis,  10.00         " 

Syrup,  aurant.  flor.,         30.00         " 
Aquse  aurant.  q.  s.  ad   120.00         " 

M.  &  Sig. — One  teaspoonful  with  water  every  three 
hours. 

In  the  more  chronic  forms  counter-irritation  and  resolvents 
may  be  applied. 

I^     Potassii  iodidi,  3.0  grammes  ; 

lodi  puri,  0.3  gramme; 

Ext.  belladonnse,  0.3         " 

Ung.  simplicis,  30.0  grammes. 

M.     Ft.  ung. 

Sig. — Apply  twice  a  day. 

In  all  these  conditions  a  tightly  fitting  suspensory,  giving 
support  to  the  part,  should  be  worn.  That  of  the  Zeissl- 
Langelbert  pattern  is  serviceable.  Massage  and  moist  appli- 
cations, especially  at  night,  should  be  carried  out  for  months 
after  the  acute  attack.  In  most  cases  obliteration  of  the  vas 
occurs,  hence  no  secretion  from  the  involved  testicle  reaches 
the  seminal  vesicles,  and  an  oligospermia  is  the  outcome.  If 
obliteration  occurs  on  both  sides,  complete  absence  of  sper- 
matozoa (azoospermia)  is  seen,  necessarily  causing  sterility. 
In  chronic  recurrent  cases  of  epididymitis  removal  of  the 
entire  involved  part  is  to  be  advised. 


172    TUBERCULOSIS   OF  THE  TESTIS  AND  EPIDIDYMIS. 

Inflammation  of  the  Testes  (Orchitis). 

Etiology. — This  is  practically  clue  to  the  same  causes  as 
epididymitis.  The  metastatic  forms  are  more  frequent.  In 
parotitis  it  is  not  uncommon  for  orchitis  to  exist  as  a  compli- 
cation, besides  beiug  seen  occasionally  during  typhoid  fever 
or  any  other  acute  bacterial  disease.  Individuals  of  gouty 
diathesis  are  also  aifected. 

Symptoms. — In  palpating  the  testis  it  is  to  be  differentiated 
from  the  epididymis  ;  if  this  is  not  readily  done,  then  a  peri- 
orchitis is  present.  The  pain  is  just  as  severe  usually,  and 
the  other  symptoms  resemble  those  of  epididymitis  to  such  an 
extent  that  it  becomes  unnecessary  to  repeat  them  here.  The 
outcome  is,  however,  somewhat  different.  Once  in  a  while 
gangrene  may  result ;  suppurative  processes  also  are  probably 
somewhat  more  common,  and,  besides,  atrophy  of  the  testicles 
is  not  at  all  unusual. 

Treatment. — This  is  practically  the  same,  except  that  in 
those  of  rheumatic  diathesis  large  doses  of  salicylate  of 
sodium  may  give  relief.  If  gangrene  or  septic  processes  set 
in,  surgical  treatment  must  eventually  be  instituted.  These 
same  conditions  may  also  be  noticed  in  cases  of  epididymitis. 

Fungus  testis  is  the  protrusion  of  testicular  substance  from 
an  opening  through  the  integument,  caused  occasionally  by 
the  rupturing  of  the  tunica  propria  which  had  become  adher- 
ent to  the  skin.  The  remaining  part  of  the  testicle  can  some- 
times be  saved,  but  in  most  cases  it  is  necessary  to  remove 
the  testicle  by  surgical  procedure. 

Tuberculosis  of  the  Testis  and  Epididymis. 

Etiology. — Tuberculosis  of  the  testis  or  epididymis,  most 
often  in  the  latter,  may  arise  in  individuals  otherwise  perfectly 
liealthy  and  free  from  any  other  tuberculous  processes  else- 
where in  the  body.  In  a  large  number  of  cases  it  is  distinctly 
metastatic,  as  from  pulmonary  processes.  It  may  arise  also  as 
a  descending  pathological  process  when  the  primary  focus  is  in 
the  kidney  or  prostate.  It  may  be  the  starting-point  for  the 
ascending  affection  involving  the  urogenital  structures.    There 


TUBERCULOSIS  OF  THE  TESTIS  AND  EPIDIDYMIS.   173 

can  be  no  question  whatsoever  that  a  predisposition  for  the 
primary  beginning  in  the  testicle  is  a  traumatism  or  some 
inflammatory  process  which  causes  a  locus  minoris  resistentice. 
It  occurs  most  often  in  youth  and  early  manhood,  and  practi- 
cally always  attacks  the  epididymis  first. 

Symptoms. — It  characterizes  itself  by  fairly  rapid  formation 
of  numerous  hard  nodules  in  both  the  head  and  tail  of  the 
epididymis  ;  most  frequently  with  but  little  pain,  so  that  the 
patient  does  not  have  his  attention  immediately  attracted  to  his 
condition.  Within  from  five  to  ten  weeks  the  nodules  may  be- 
come the  size  of  a  walnut,  and  adherent  to  the  integument,  and 
then  readily  open  spontaneously,  from  which  a  cheesy,  sero- 
purulent  discharge  flows,  sometimes  for  an  indefinite  time.  It 
may  occur  without  any  rise  in  temperature,  although  a  slight 
anaemia  may  result.  In  65  per  cent,  of  cases  the  other  testicle 
becomes  involved.  Whenever  the  process  has  existed  for 
any  length  of  time,  the  testis  proper  becomes  affected — cer- 
tainly the  vas  deferens,  etc.,  if  it  is  an  ascending  process. 

Prognosis. — This  depends  partly  on  whether  or  not  other 
parts  are  involved.  If  they  are,  it  is  unfavorable.  In  the 
primary  cases  it  depends  on  the  treatment. 

Treatment. — Castration  is  the  radical  treatment,  and  it  cer- 
tainly gives  the  best  results.  Nevertheless  it  must  not  be 
advised  in  a  reckless  manner,  as  in  the  cases  of  double-sided 
tuberculous  epididymitis  it  would  mean  the  removal  of  two 
organs  having  important  functions.  Hence  the  more  conser- 
vative procedures  are  to  be  advised  ;  if  only  the  epididymis  is 
involved,  a  resection  of  the  diseased  part  is  to  be  undertaken. 
If  a  sinus  remains  after  a  rupture  of  a  tuberculous  abscess, 
and  especially  if  there  is  present  an  involvement  of  other 
parts,  curettement  and  local  treatment  are  desirable,  with — 

I^     Guaiacoli,  5.00  grammes ; 

Ext.  belladonnas,  0.25  gramme  ; 

Ung.  simplicis,  25.00  grammes. 

General  dietetic  and  hygienic  treatment  are  imperative, 
together  with  removal  to  a  suitable  climate  when  possible. 


174       SYPHILIS  OF  THE  TESTIS  AND  EPIDIDYMIS. 

Syphilis  of  the  Testis  and  Epididymis. 

Etiology. — In  acquired  syphilis  the  testis  may  be  aifected 
either  during  the  secondary  or  more  often  in  the  tertiary 
period.  Syphilitic  deposits  may  also  be  seen  in  hereditary 
syphilis.  Traumatism  appears  to  predispose,  as  direct  con- 
nection with  it  has  often  been  demonstrated. 

Symptoms. — Syphilis,  in  contradistinction  to  tuberculosis, 
affects  the  testis  most  frequently.  A  diffuse  swelling,  usu- 
ally in  one  or  both  testicles,  rarely  causing  an  unevenness,  is 
to  be  felt,  and  begins  to  show  itself  with  almost  complete 
absence  of  pain  ;  but  if  there  is  pain,  it  is  due  more  to  the 
traction  and  tension  on  the  cord  on  account  of  the  increased 
size  and  weight.  No  constitutional  symptoms  are  necessarily 
present.  The  swelling  disappears  by  degrees,  owing  to  an 
interstitial  process,  and  the  testicle  may  gradually  atrophy  ; 
or  the  swelling  may  increase  in  size  and  rupture  sponta- 
neously, and  a  serum-like  fluid  escape,  leaving  a  funnel- 
shaped  ulcer  with  undermined  edges.  This  gradually  fills 
up  with  testicular  substance  and  becomes  covered  with  granu- 
lations— referred  to  as  fungus  benignus  syphiliticus. 

It  is  almost  needless  to  state  that  the  syphilitic  process 
may  involve  the  epididymis. 

Diagnosis. — It  is  to  be  remembered  that  the  epididymis 
is  distinctly  and  easily  palpated  from  the  testis.  Besides,  the 
cord  is  unaffected.  The  testis  may  attain  the  size  of  an 
orange,  and  as  the  parenchyma  may  be  unequally  involved, 
the  surface  may  be  uneven.  It  is  to  be  differentiated 
from  a  chronic  epididymitis,  tuberculous  processes,  and 
tumors. 

Prognosis  and  Treatment. — If  it  is  recognized  early  and 
proper  treatment  instituted,  there  must  practically  be  com- 
plete absorption.  If  first  seen  after  gummatous  breaking 
down  and  the  establishment  of  a  sinus,  it  is  often  best  to 
curette  and  pack  with  iodoform  gauze,  or  to  apply  mer- 
curial ointment  and  institute  energetic  antisyphilitic  treat- 
ment. 


NEOPLASMS  OF  THE   TESTIS  AND  EPIDIDYMIS.     175 

Cysts  of  the  Testis  and  Epididymis. 

Varieties. — One  of  the  most  common  tumors  found  in  this 
location  are  the  cysts  (the  hydatids  of  Morgagni),  situated  at 
the  upper  pole  of  the  testis  and  just  below  the  head  of  the 
epididymis.  The  most  important  cyst,  however,  is  the  col- 
lection of  the  secretion  of  the  testis,  called  spermatocele.  It 
probably  consists  of  a  dilatation  of  a  part  of  the  vasa  eifer- 
entia,  and  hence  is  a  retention  of  the  testicular  fluid. 

Symptoms. — In  most  cases  the  cysts  may  readily  be  pal- 
pated from  both  testes  and  epididymis,  and  are  usually 
spherical  or  oval  in  shape.  They  have  a  peculiar  doughy 
consistency.  Aspiration  of  the  contents  is  indicated,  and  if 
microscopical  examination  reveals  the  presence  of  spermato- 
zoa, the  diagnosis  is  confirmed. 

Treatment. — Extirpation  of  the  sac,  no  matter  what  the 
kind  of  cyst  may  be. 

Neoplasms  of  the  Testis  and  Epididymis. 

Varieties  and  Symptoms. — These  are  not  uncommon,  and 
there  is  scarcely  an  organ  in  the  body  that  can  claim  a  greater 
variety. 

Those  derived  from  the  epithelia,  or  carcinomatous  tumors, 
are  not  rare.  Both  medullary  and  scirrhus  types  are  met 
with.  The  former  is  more  common,  and  takes  quite  a  rapid 
growth.  As  soon  as  the  tunica  becomes  involved,  an  uneven 
and  fairly  hard,  nodulated  condition  is  first  noticed.  Pains 
arise  only  when  there  is  a  rapid  increase  in  size  and  when 
the  inguinal  glands  become  involved.  The  epididymis  does 
not  become  involved  quickly,  and  neither  are  inflammatory 
processes  noticeable.  Adenomata  have  also  been  observed. 
Castration  is  necessary  in  these  cases. 

Dermoids  and  teratomata  have  also  been  recorded.  These 
embryonal  tumors  are,  however,  comparatively  benign.  Ex- 
cision, or  in  certain  cases  castration,  becomes  necessary. 

The  tumors  derived  from  the  connective  tissue  are  the 
fibroma,  myoma,,  enchondroma,  lipoma,  and  myxoma,  and, 
most  important  of  all,  sarcoma.     They  are  primary  on  one 


176     NEOPLASMS  OF  THE  TESTIS  AND  EPIDIDYMIS. 

or  both  sides,  either  in  the  testis  or  epididymis,  and  are  most 
common  in  childiiood.  They  grow  rapidly,  usually  without 
pain.  They  rupture  spontaneously,  and  the  fungus  malignus 
is  thus  produced.  As  it  grows  the  consistency  becomes 
softer,  and  cystosareoma  may  give  rise  to  various  findings. 

Carcinoma  is  usually  found  in  the  later  years  of  life. 
Whenever  the  cord  and  the  inguinal  glands  become  involved, 
the  diagnosis  may  readily  be  made. 

Prognosis  is  unfavorable. 

Treatment  must  be  radical  extirpation. 


Differential  Diagnosis  of  Tumors  of  the  Testis. 


Syphilitic  Testis.         Tuberculous  Testis. 


History    .... 
Commencement 

Growth    .... 


Pain  and  tender- 
ness     


Size  and  contour 

Number   .... 
Complications  . 


Medicinal  treat- 
ment   


Syphilitic. 
Testis  most  often. 

Slow. 


Tuberculous. 

Epididymis  most 
often. 

As  a  rule,  quite  slow; 
may  be  acute  ex- 
acerbations. 


Almost    always    ab-    But  slight, 
sent. 


Size  of  a  pear.  May 
atrophy ;  then 
usually  hard.  Epi- 
didymis free. 

At  first  one ;  later  the 
other. 

Hydrocele  often 
present.  Inguinal 
glands  not  i  n- 
volved.  Seminal 
vesicles  and  cord 
and  prostate  gland 
not  involved.  Gen- 
eral adenopathy 
may  be  present. 

Keacts  to  antisyphil- 
itic  treatment. 


Epididymis  irreg- 
ularly enlarged, 
nodulated.  Sinus 
may  exist. 

Consecutive  in- 
volvement. 

Hydrocele  is  occa- 
sionally present. 
Inguinal  glands 
may  be  acutely  in- 
volved. Seminal 
vesicles  and  cord 
and  prostate  gland 
usually  involved. 


Malignant  Neo- 
plasms. 

(Traumatic.) 

Testis. 

Usually  rapid, 
though  may  lie 
dormant  for  long 
time. 

At  beginning  absent ; 

later     sharp    and 

shooting. 
Frequently  of  large 

size,      nodulated 

tunica,  fungus 

growth. 
Usually  single. 

Unusual  to  have  hy- 
drocele. Inguinal 
glands  always  be- 
come  enlarged. 
Seminal  vesicles 
and  prostate  not 
involved.  Often 
cord  is  involved. 


Sometimes  good  re-    No  effect, 
suits  from  funeral 
tonics. 


Castration, 


The  indications  for  castration  are  easily  included  in  the 
following  :  malignant  tumors,  benign  tumors  if  the  size  causes 
inconvenience,  tuberculosis,  certain  forms  of  syphilis,  injuries 
with  or  without  gangrene,  and  sejitic  ]irocesses  of  the  testes. 

Technic. — (1)  It  is  usually  sufficient  to  make  an   incision 


NEUROSIS  OF  THE  TESTICLE.  Ill 

over  the  most  prominent  part  of  the  tumor^  through  the  skin, 
tunica  dartos,  and  coverings  of  the  testis.  Remove  the  tes- 
ticle and  ligate  the  cord  and  vessels  as  high  as  possible.  After 
all  hemorrhage  has  been  checked  unite  the  skin.  If  the  skin 
is  attached  to  any  process,  it  is  best  to  remove  it.  If  tuber- 
culosis of  cord  or  malignant  tumors  are  present,  incision 
should  be  made  to  reach  the  parts  passing  through  the 
inguinal  canal.  The  entire  cord  should  be  removed  either 
through  the  incision  or  with  the  aid  of  the  Zuckerkandl 
incision  of  the  perineum. 

(2)  Another  very  simple  method  of  castration  is  to  make 
an  incision  centred  over  the  superficial  abdominal  ring,  and 
extending  downward  pai'allel  with  the  cord.  Deep  dissection 
must  aim  to  reach  the  cord,  which  is  then  isolated  by  blunt 
separation.  Traction  upward  on  the  cord  will  now  shell  the 
testis  out  of  the  scrotum.  The  vas  deferens  must  be  separated 
from  the  remainder  of  the  cord  and  divulsed  out  of  the 
abdominal  cavity  by  traction  downward.  The  cord  is  then 
doubly  ligated  and  cut  across  between  the  ligatures.  The 
stump  is  pushed  into  the  inguinal  canal,  and  the  pillars  stitched 
together  to  avoid  rupture. 

Neurosis  of  the  Testicle. 

Varieties. — Neurosis  of  the  testicle  may  be  either  an  extreme 
irritability  or  an  actual  neuralgia. 

Symptoms. — The  irritability  manifests  itself  in  the  occur- 
rence of  dull  pains  during  physical  exercise  or  sexual  ex- 
citement. It  results,  sometimes,  in  a  spasm  of  the  cre- 
master  muscle,  so  that  the  testicle  is  drawn  high  up  toward 
the  abdominal  ring  and  presses  around  it  tightly,  adding  to 
the  discomfort  of  the  patient.  During  and  after  intercourse 
the  testicle  becomes  the  seat  of  dull  pain,  which  lasts  for  some 
time.  The  actual  neuralgia  appears  in  attacks  which  take 
place  at  more  or  less  regular  intervals.  Previous  to  the 
attacks,  and  during  their  occurrence,  the  bladder,  as  a  rule, 
is  highly  irritated. 

The  causes  of  these  conditions  are  either  sexual  excesses 

12— v.  D- 


178  JSfEUEOSIS  OF  THE   TESTICLE. 

and  undue  stimulation,  or  they  are  the  consequences  of  exces- 
sive masturbation.  Sometimes  neuralgia  appears  in  the  course 
of  an  old  malarial  infection.  General  neurasthenia  or  organic 
diseases  of  the  spinal  cord  may  produce  localized  symptoms 
in  the  testicles. 

The  treatment  will,  at  first,  remove  any  evident  cause. 
Sexual  intercourse,  and  particularly  masturbation,  must  be 
avoided.  If  posterior  urethritis  or  prostatitis  is  present,  these 
conditions  must  be  properly  attended  to.  Malaria  calls  for 
the  specific  treatment  of  this  disease.  General  neurasthenia 
must  be  treated  by  the  administration  of  tonics  and  hydro- 
pathic measures.  A  faradic  current  is  quite  often  used  to 
good  advantage. 

QUESTIONS  ON  THE  INJURIES  AND  DISEASES  OF  THE    SCROTUM, 
TESTICLES,  COEDS,  AND  THEIR  COVERINGS. 

Enumerate  the  congenital  anomalies  of  the  testicles. 

What  is  retentio  testis? 

What  is  monorchismus?  cryptorchidism? 

Are  individuals  of  the  latter  type  sterile  ? 

Describe  the  condition  of  retention  of  the  testicles. 

What  are  often  the  results  in  these  cases  ?    What  is  the  treatment? 

What  is  meant  by  orchidopexy  ? 

What  is  meant  by  inversio  testis? 

What  is  meant  by  ectopia  testis? 

What  is  meant  by  hsematoma  scroti  ? 

Do  neoplasms  of  the  scrotum  ever  occur?     Enumerate  them. 

What  is  their  treatment? 

What  is  meant  by  a  hsematoma  of  the  coverings  of  cord  or  testicle?  What 
different  types  are  there?     What  is  their  treatment? 

What  is  meant  by  acute  hydrocele  ?  by  chronic  hydrocele  ? 

What  are  their  causes?  Describe  their  different  varieties,  as  funicularis, 
communis,  communicans,  bilocularis,  and  multilocularis. 

What  are  the  symptoms  of  these  different  varieties  ? 

What  is  the  prognosis? 

What  is  their  treatment?  Give  the  latter  in  detail  for  all  the  different 
varieties. 

What  is  varicocele? 

What  do  you  know  about  varicocele  ? 

How  is  the  diagnosis  made  ? 

From  what  must  the  condition  be  differentiated? 

To  what  condition  may  varicocele  lead  ? 

What  is  the  treatment  ? 

Describe  the  operation  for  varicocele. 

Are  injuries  to  the  external  genitalia  common? 

What  is  meant  by  dislocation  of  the  testicle? 

Wliat  is  epididymitis? 


ECTOPIA    VESICA.  179 

In  what  diflferent  ways  may  this  arise  ?    Is  this  a  common  complication  of 
urethritis?     How  do  you  account  for  this ? 
What  are  the  symptoms  ? 

What  is  meant  by  funiculitis  ? 

From  what  must  this  condition  be  diiferentiated  ? 

What  is  the  treatmeut?     Describe  in  detail  the  different  modes. 

If  complicated  with  a  urethritis,  should  the  local  treatment  of  the  urethritis 
be  discontinued  ? 

If  chronic  and  recurrent,  what  course  may  be  necessary  to  take? 

What  is  meant  by  orchitis  ?    What  are  the  causes  ?    Is  it  often  complicated 
with  epididymitis  ? 

In  the  Course  of  what  general  disease  does  it  occur  as  a  complication  ? 

What  is  the  treatment  ? 

What  is  meant  by  fungus  testis? 

How  is  this  condition  treated  ? 

Does  tuberculosis  of  the  testicle  or  epididymis  ever  occur  ? 

In  what  manner  may  it  arise? 

How  is  the  diagnosis  made  ? 

What  is  the  prognosis? 

What  is  the  treatment  ? 

What  is  meant  by  castration  ?    Describe  the  operation  ? 

Does  syphilis  of  the  testicle  or  epididymis  ever  occur? 

Which  is  most  commonly  affected? 

How  is  the  diagnosis  made  ? 

What  is  the  prognosis  ? 

What  is  the  treatment  ? 

Enumerate  the  different  tumors  of  the  testis  and  epididymis. 

Are  the  varieties  of  neoplasm  of  these  organs  very  numerous? 

Describe  the  more  common  varieties. 

How  is  the  differential  diagnosis  of  the  different  neoplasms  made  ? 

What  is  their  prognosis  ? 

Describe  in  detail  the  differential  diagnosis  of  syphilis,  tuberculosis,  and 
malignant  neoplasms  of  these  organs. 

What  is  meant  by  neurosis  of  the  testicles  ? 

Describe  such  a  condition. 

On  what  can  a  diagnosis  positively  be  established  ? 

What  is  the  treatment  ? 

MALFORMATIONS,  INJURIES,  AND  DISEASES  OF 
THE  BLADDER.. 

Ectopia  Vesicae. 

Pathology  and  Symptoms. — This  is  a  congenital  malforma- 
tion, in  which  the  anterior  abdominal  and  vesical  walls  are 
absent,  and  where  the  posterior  wall  and  fundus  protrude 
through  the  abdominal  opening.  It  is  called  also  exstrophy 
of  the  bladder.  At  the  same  time  union  of  the  symphysis 
pubis  and  external  genitaha  exists.  The  condition  presents 
a  characteristic  appearance :  The    mucous   membrane  is  ex- 


180     MALFORMATIONS,  INJURIES,  DISEASES  OF  BLADDER 

posed  and  appears  irritated,  and  on  close  examination  the 
urethral  openings  may  be  seen. 

Treatment. — Various  operations  have  been  devised  for  the 
relief  of  this  condition.  All  are  attempts  either  at  direct 
union  of  the  edges,  plastic,  or  to  deviate  the  course  of  the 
urine.  Maydl's  operation  is  probably  the  most  successful. 
It  consists  of  transplanting  the  ureters  with  the  bladder 
mucosa  about  the  ureteral  openings  into  the  rectum.  All 
such  operations  are  grave  and  often  fail. 

Entire  absence  of  the  bladder  has  been  noted.  Double 
bladder,  or  vesica  duplex,  has  also  been  reported.  Multiple 
bladders,  so  called,  are  probably  sacculated  conditions  of  the 
bladder. 

Hernia  of  the  Bladder. 

Varieties. — This  is  a  not  uncommon  condition,  and  is  occa- 
sionally noticed  during  hernia  operations.  The  anterior  or  one 
of  the  lateral  walls  which  are  uncovered  by  the  peritoneum 
protrude  into  the  inguinal  canal.  If  this  prolapse  becomes 
larger,  then  a  certain  amount  of  peritoneum  is  pushed  into 
the  canal  and  the  bladder  follows  ;  this,  then,  is  regarded  as 
a  true  hernia  of  the  bladder ;  in  other  words,  hernia  of  the 
bladder  may  be  either  extraperitoneal  or  intraperitoneal,  or  a 
combination  of  these  two.  These  types  have  also  all  been 
referred  to  as  cystocele. 

Causes. — Among  these,  strictures  and  prostatic  hypertrophy 
must  be  considered,  especially  as  these  cause  abnormal  disten- 
tion of  the  bladder  with  residual  urine.  With  weakened 
muscular  walls,  repeated  holding  of  the  urine,  or  overdis- 
tending  the  bladder  may  give  rise  to  these  conditions. 

Symptoms. — These  naturally  refer  to  abnormalities  in  the 
act  of  urination.  The  patients  must  often  place  themselves 
in  peculiar  positions  in  order  to  urinate  :  most  frequently 
always  exactly  in  the  same  position,  and  must  even  exert 
pressure  on  the  hernia  in  order  to  aid  urination.  If  associated 
loith  an  omental  or  intestinal  hernia,  if  of  any  size,  differentia- 
tion can  often  be  made  by  the  aid  of  palpation  and  percussion, 
and,  most  important  of  all,  icifh  the  catheter,  because  evacuation 


INJURIES  TO   THE  BLADDER.  181 

of  the  bladder  icill  decrease  the  size  of  the  hernial  protrusion. 
If  it  is  possible  to  make  a  diagnosis  of  this  coudition,  or  if 
met  with,  or  even  if  the  bladder  is  accidentally  injured  during 
an  operation,  the  radical  operation  is  to  be  advised.  A  supra- 
pubic incision  is  made,  resection  of  the  affected  area,  careful 
suturing  of  entire  bladder-wall.  Small  gauze  drain  in  pre- 
vesicular  space  and  a  permanent  catheter  placed  in  the 
urethra. 

Cystocele  Vaginalis. 

Symptoms. — This  is  a  prolapse  of  the  bladder,  or  a  part  of 
it,  toward  the  vagina.  It  occasionally  occurs  after  labor,  and 
also  in  cases  of  prolapse  of  the  uterus.  In  some  cases  it  may 
be  so  severe  that  the  urethra  is  hio-her  than  the  bladder. 

Treatment. — The  cause  demands  removal,  and  often  plastic 
restoration  of  the  anterior  vaginal  wall  will  be  found  neces- 
sary. 

Injuries  to  the  Bladder. 

Etiology. — These  may  occur  during  instrumentation,  as 
during  a  litholapaxy,  cystoscopy,  or  even  catheterization,  etc. 
Rupture  of  the  bladder  occurs,  however,  more  readily  when 
the  bladder  is  full  than  when  empty,  because  a  blow  may 
then  act  directly  on  the  bladder,  extending  over  the  symphysis 
pubis.  Injuries  to  the  pelvis,  especially  fracture  of  the  pel- 
vis, are  frequently  associated  with  rupture  of  the  bladder. 
They  occur  most  frequently  in  men — nine  out  of  ten  cases. 
For  practical  purposes  these  injuries  are  divided  into  two 
classes  :  (1)  Intraperitoneal  rupture  is  more  common, — two 
out  of  three  cases, — and  occurs  most  frequently  on  the  pos- 
terior wall  or  apex.  (2)  Extraperitoneal  rupture  is  found 
most  often  in  the  anterior  wall. 

Symptoms  and  Diagnosis. — As  regards  the  immediate  diag- 
nosis of  rupture  of  the  bladder,  this  is  not  always  an  easy 
matter.  Besides,  to  differentiate  absolutely  between  extra- 
peritoneal and  intraperitoneal,  or  a  combination  of  both,  is 
also  difficult.  As  these  cases  are  frequently  observed  in  the 
intoxicated,  and  also  as  shock  often  accompanies  rupture,  the 


182     HALF  OEM  A  TIONS,  IN  J  UR  lES,  DISEASES  OF  B  LA  DDER 

subjective  symptoms  are  delayed  until  either  or  both  of  these 
conditions  pass,  and  tenesmus  usually  follows.  This  is  accom- 
panied by  an  inability  to  pass  urine,  although  small  quantities 
of  blood  or  of  bloody  urine  may  be  passed.  At  the  same 
time  severe  pains  about  the  entire  bladder  region  and  the 
perineum  are  almost  constant.  Excessive  tenderness  about 
these  parts  is  also  usually  present.  Occasionally,  when  the 
rupture  is  extraperitoneal,  a  tumor  above  the  pubes  may  be 
felt. 

If  a  positive  diagnosis  of  rupture  of  the  bladder  can  be  made 
without  the  use  of  the  catheter,  this  method  is  to  be  preferred. 
If,  however,  this  becomes  necessary,  the  catheter  should  be 
passed  under  the  strictest  aseptic  precautions.  When  the  eye 
of  the  instrument  is  in  the  bladder,  no  urine  is  withdrawn, 
as  the  bladder  is  collapsed.  If  the  catheter  is  manipulated, 
bloody  urine  containing  debris  may  be  drawn  off.  This  is 
accounted  for  by  the  fact  that  the  eye  of  the  catheter  passed 
through  the  opening  and  entered  either  the  abdominal  cavity 
or  the  prevesicular  space.  If  the  rupture  be  extraperitoneal, 
symptoms  of  urinary  infiltration  immediately  arise.  In  about 
from  twenty-four  to  forty-eight  hours,  if  the  rupture  is  intra- 
peritoneal, symptoms  of  peritonitis  begin  to  apj^ear. 

Rarely  does  a  bladder  rupture  during  an  intravesicular 
operative  procedure,  although  this  has  been  known  to  occur. 
In  these  cases  the  distended  bladder,  which  was  readily  seen 
and  felt  above  the  pubes,  suddenly  decreases  in  size,  disap- 
pears, and  can  no  longer  be  felt.  Besides,  a  catheter  intro- 
duced into  the  bladder  no  longer  withdraws  fluid. 

Prognosis. — It  is  needless  to  state  that  the  earlier  the  diag- 
nosis and  the  sooner  treatment  is  instituted,  the  more  favorable 
is  the  prognosis. 

The  treatment,  naturally,  must  be  surgical,  with  the  purpose 
of  preventing  peritonitis  and  urinary  infiltration.  With  the 
patient  in  the  Trendelenburg  position,  an  incision  from  4  to  6 
cm.  long  is  made  in  the  median  line,  above  the  pubes.  Care 
should  be  taken  to  avoid  the  peritoneum.  When  the  rupture 
is  found,  the  bladder  should,  be  explored  thoroughly  with  the  fin- 
ger, to  note  the  absence  of  any  other  tear.     In  some  cases  the 


FISTULA    OF  THE  BLADDER— CYSTFTIS.  183 

bladder  can  be  closed  in  two  layers,  drainage  instituted  in  the 
prevesical  space,  and  a  permanent  catheter  introduced  and 
allowed  to  remain  in  the  urethra.  If  the  rupture  is  not 
found  in  the  anterior  or  the  lateral  walls,  laparotomy  should 
be  performed.  The  part  of  the  bladder  covered  by  the  peri- 
toneum is  examined,  and  when  the  tear  is  found,  it  should  be 
united  in  layers.  Of  course,  the  abdominal  cavity  is  carefully 
cleansed  and  drainage  is  allowed  to  remain.  Many  deviations 
in  technique  are  necessary,  as  each  case  differs  from  all  others. 

Fistula  of  the  Bladder. 

False  passages  connecting  the  bladder  with  the  abdominal 
wall,  rectum,  and  vagina"  are  not  uncommon.  These  occur 
occasionally  during  the  course  of  chronic  inflammatory  dis- 
eases, and  are  also  made  artificially.  Whenever  it  becomes 
necessary  to  close  the  fistula,  operative  procedures  varying 
with  the  different  cases  should  be  employed. 

Cystitis. 

Cystitis  is  an  inflammation  of  the  bladder-wall  which  may 
be  confined  to  the  mucous  membrane  or  involve  the  submucous 
layers,  and  eventually  spread  into  the  muscular  coat.  If  the 
inflammation  passes  into  the  connective  tissues  which  surround 
the  viscus,  we  speak  of  pericystitis. 

Causes. — While  in  very  rare  instances  a  slight  inflammation 
of  the  bladder  may  be  produced  by  chemical  influence,  there 
is  no  doubt  that  in  an  overwhelming  majority  of  cases  of 
cystitis  the  origin  is  bacterial.  There  is  scarcely  one  of  the 
pathological  germs  which  cannot  produce  cystitis.  The  con- 
dition is  most  frequently  caused  by  the  gonococcus,  bacillus 
coli  communis,  bacillus  typhosus,  urobacillus  liquefaciens  sep- 
ticus,  the  various  pyogenic  staphylococci  and  streptococci, 
and  the  bacillus  tuberculosis.  Retention  of  urine ;  internal 
medication  with  oils,  cantharides,  etc. ;  tumors ;  calculi ; 
traumatism  ;  or  colds  are  the  predisposing  influences  for  the 
inflammatory  action  of  the  microbes  which  may  be  present  in 
the  urethra,  ureter,  or  neighboring  parts. 


184     MALFOBMATIOXS,  IXJUFJES,  DISEASES  OF  BLADDER. 

The  symptoms  of  acute  cystitis  are  sensations  of  heaviness 
and  fulness,  eventually  of  pain  in  the  bladder.  The  desire 
for  urination  is  greatly  increased,  but  the  act  of  micturition 
brings  no  relief,  and  but  small  cj[uantities  are  passed  at  each 
act.  This  continues  both  day  and  night.  An  occasional  chill 
followed  by  quite  high  temperature  for  some  time  are  not 
unusual. 

The  urine  is  turbid,  and  usually  contains  a  large  number 
of  pus-cells,  and  in  very  acute  cases  even  red  blood-corpuscles. 
The  urine  becomes  alkaline  only  in  cases  complicated  with 
pyelitis,  or  if,  by  the  influence  of  certain  bacteria,  ammoniacal 
decomposition  of  the  urine  sets  in. 

Gonorrhceal  cystitis  is  characterized  by  a  peculiar  distribu- 
tion of  the  infected  areas.  The  inflammation  confines  itself 
to  the  trigonum,  which  appears  to  be  spotted  with  red  patches. 

Colicystitis  involves  the  mucous  membrane  more  or  less 
universally,  so  that  the  epithelial  lining  is  thrown  off  in  quite 
extensive  areas,  causing  the  inner  wall  of  the  bladder  to 
resemble  red  velvet. 

The  bacillus  tuberculosis,  as  a  rule,  confines  its  action  to  the 
trigonum,  and  gives  rise  to  the  formation  of  small  grayish 
nodules  in  the  mucous  membrane  which  eventually  ulcerate, 
thus  forming  tuberculous  ulcers.  Tuberculous  cystitis  is,  as 
a  rule,  a  very  painful  affection.  The  bladder  especially  is 
extremely  sensitive  to  dilatation  and  to  any  kind  of  instru- 
mentation ;  tenesmus,  and  often  slight  hemorrhages,  may 
exist.  The  urine  is  usually  acid.  Whenever  there  is  a  gen- 
eral cystitis,  as  caused  by  the  pyogenic  staphylococci  and 
streptococci,  a  slight  cedema  of  the  mucosa  may  be  seen. 
Later  desquamation  of  the  epithelial  cells  and  the  formation 
of  pus  are  manifest.  This  process  may  be  diffuse  over  the 
entire  inner  surface  of  the  bladder,  and  ecchymoses  may  be 
distributed  irregularly  throughout  the  entire  affected  area. 
The  enlarged  vessels  are  very  noticeable,  especiallv  within 
the  trigonum.  As  regards  the  quantity  of  pus  and  alljumin, 
the  quantity  of  the  latter  can  be  accounted  for  in  the  manner 
already  described. 

Chronic  Cystitis. — Here  the  subjective   symptoms  are  less- 


CYSTITIS.  185 

ened,  while  the  pathological  changes  become  more  and  more 
extensive  and  grave.  The  urine  becomes  turbid,  and  if,  in 
consequence  of  some  noxse,  the  process  flares  up, — which 
usually  occurs  repeatedly, — the  amount  of  pus  in  the  urine 
i  ncreases. 

In  cases  of  gonorrhceal  cystitis,  if  the  process  becomes 
chronic,  the  original  red  color  of  the  inflamed  areas  turns 
gradually  to  a  dark  brown.  Quite  often  the  infiltration 
intrudes  into  the  submucous  layers,  so  that  elevated  plaques 
are  to  be  seen,  whose  centres  occasionally  suppurate ;  in  this 
way  gonorrhoeal  ulcers  are  produced. 

If  a  colicystitis  becomes  chronic,  the  inflamed  mucosa  as- 
sumes more  and  more  the  character  of  a  granulating  surface. 
If  such  cases  of  cystitis  are  neglected,  ulcers,  which  may  be 
found  all  over  the  inner  wall  of  the  bladder,  are  not  uncom- 
monly formed.  If  the  inflammation  involves  the  submucous 
layers  to  a  great  extent,  the  so-called  parenchymatous  cystitis 
develops,  and  the  bladder-wall  becomes  thickened,  sensitive, 
and  rigid.  In  its  higher  development  this  condition  leads  to 
the  establishment  of  cystitis  dolorosa,  in  which  the  bladder 
becomes  contracted,  so  that  even  the  smallest  amount  of 
fluid  cannot  be  retained.  Every  drop  of  fluid  is  expressed 
through  contraction  of  the  bladder,  and  these  contractions 
are  extremely  painful.  The  bladder  is  continually  the  seat 
of  excruciating  pains,  and  the  whole  region  is  extremely  sen- 
sitive to  the  touch. 

Whenever  a  posterior  urethritis  exists,  the  bladder  mucosa 
immediately  adjoining  the  internal  urethral  orifice  becomes 
almost  certainly  affected  by  extension  of  the  process  from 
the  posterior  urethra.  In  these  cases  it  is  the  trigonum 
which  is  chiefly  involved ;  this  condition  has  been  called 
cystitis  colli — inflammation  of  the  neck  of  the  bladder.  Ana- 
tomically, no  neck  exists,  hence  the  term  is  incorrect,  and 
Finger  introduced  the  term  urethrocystitis,  which  is  to  be 
used  in  the  class  of  cases  referred  to.  It  occurs  during  the 
course  of  an  acute  or  chronic  urethritis,  and  excesses  of  all  kinds 
are  known  to  be  the  most  important  factors  in  these  cases. 

In  cases  of  cystitis   the  urine  will  be  found  to  be  turbid 


186     MALFORMATIONS,  INJURIES,  DISEASES  OF  BLADDER. 

with  pus ;  hence  the  Thompson  two-glass  method  shows  the 
urine  to  be  turbid  in  both  glasses.  In  all  cases  it  is  necessary 
to  establish  whether  or  not  the  pathological  findings  of  the 
urine  are  due  entirely  to  the  bladder  affections  or  whether 
admixed  with  substances  from  the  ureters,  pelves,  or  kidneys. 

Treatment. — The  treatment  in  acute  cases  of  cystitis  will 
restrict  itself  to  general  measures  and  symptomatic  applica- 
tions :  practically,  rest,  diet,  depletion  of  pelvis,  baths,  and 
medicinal  treatment  are  necessary.  The  patient  is  put  on  a 
bland  diet,  and  alcoholic  beverages  are  strictly  prohibited  ; 
laxatives,  rest  in  bed,  and  hip-baths  are  ordered.  As  a  rule, 
hot  poultices  over  the  pubes  and  perineum  reduce  the  pain 
and  lessen  the  frequency  of  urination. 

The  medicinal  treatment  separates  itself  into  two  divisions  : 

I.  Internal  Medication, — Most  important  are  the  anodynes, 
which  are  absolutely  necessary  on  account  of  the  symptoms. 
The  indications  are  pain,  frequency  of  urination,  and  tenes- 
mus. Whenever  a  case  of  cystitis  presents  itself,  in  order 
to  make  any  progress  these  symptoms  must  be  relieved,  as 
the  pain,  the  frequent  urination,  and  the  tenesmus  tend  only 
to  increase  the  trouble.  As  much  anodyne  should  be  given 
as  is  necessary  to  overcome  the  symptoms.  Sometimes  as 
much  as  0.25  gramme  of  morphine  or  0.5  gramme  of  codein 
may  be  required  daily,  both  in  divided  doses.  In  prescrib- 
ing an  anodyne,  a  small  dose  should  first  be  given  to  ascertain 
whether  the  patient  has  an  idiosyncrasy  for  the  drug.  If  this 
is  not  enough  to  overcome  the  pain,  etc.,  and  no  idiosyncrasy 
presents  itself,  then  increase  as  necessity  demands. 

Opiates  and  anodynes  are  given  either  internally  or  by  the 
rectum.  If  the  latter,  some  formula  like  the  following  is 
very  useful : 

]^     Ext.  opii,  0.25  gramme  ; 

Ext.  belladonna,  0.10       " 

Ichthyolis,  2.50  grammes ; 

Butyri  cocse,  q.  s. 

M.     Ft.  in  suppos.  rect.  No.  x. 

Sig. — One  every  three  or  four  hours. 


CYSTITIS.  187 

Opium  is  frequently  sufficient,  but  morphine  should  be 
given  at  once  if  opium  has  no  immediate  effect. 

I^      Decoct,  seminis  lini,     500.0  grammes; 
Tinct.  opii,  1.0-2.0         " 

Aquae  laurocerasi,  15.0         " 

Sig. — One  tablespoonful  every  one  to  two  hours. 

i^     Fol.  uvse  ursi, 

Fol.  buchu,  aa  30.0  grammes. 

Add  a  pint  of  boiling  water  to  a  tablespoonful  of  the  fore- 
going tea,  let  it  stand  for  a  while,  and  then  strain ;  a  cupful 
every  hour  should  be  ordered. 

I^      Liq.  potassii,  10.0  grammes  ; 

Tinct.  hyoscyami,  20.0         " 

Syr.  acacise,       q.  s.  ad  90.0         " 

Sig. — A  teaspoonful  every  two  to  three  hours,  well 
diluted  with  water. 

In  some  cases  there  may  be  severe  hemorrhages.  If  such 
a  condition  exists,  it  must  be  taken  into  consideration.  The 
following  may  then  be  of  service : 

]^      Liq.  ferri  sesquichlor.,    1.0  grammes; 
Aquse  destillatse,         150.0         " 
Syr.  corticis  aurantii,     25.0         " 

Sig. — One  tablespoonful  every  hour.     Take  with 
water. 

Fluid  extract  of  ergot  and  hydrastis  may  readily  be  added 
to  the  preceding. 

Erections  and  other  symptoms  must  be  treated  accordingly. 

^     Ext.  cannabis  indicse, 

Ext.  hyoscyami,        aa  0.3  gramme  ; 
Sacch.  lactis,  3.0  grammes. 

Div.  in  pulv.  No.  x. 

Sig. — One  every  three  hours. 


ISH     MALFORMATIONS,  INJURIES,  DISEASES  OF  BLADDER. 

^     Acidi  camphorici, 

Sacch.  alb.,  aa  2.0  grammes. 

Div.  in  caps.  No.  x. 
Sig. — One  every  four  hours. 

The  urine  is  usually  acid  and  of  high  specific  gravity;  but 
when  the  urine  is  alkaline,  alkaline  diuretics  should  rarely 
be  given.  Where  phosphaturia  exists,  urotropin,  salol,  am- 
inoform,  and  cystogen  are  given  in  order  to  cause  the  urine 
to  become  acid.  Sodium  salicylate,  in  1-gramme  doses,  given 
four  or  five  times  daily,  has  a  tendency  to  render  it  acid. 

II.  Local  Treatment. — This  is  omitted  during  acute  attacks, 
and  should  be  instituted  only  when  complicated  with  reten- 
tion of  urine.  Then  catheterization  under  aseptic  conditions 
and  irrigation  with  mild  solutions,  as  warm  saturated  solu- 
tion of  boric  acid,  are  necessary. 

In  the  subacute  stages  the  injection  of  from  5  to  15  c.c.  of 
a  10  per  cent,  iodoform  emulsion  affords  relief  from  the  pain 
and  has  a  healing  effect  upon  the  inflamed  mucosa. 

Formulae  like  the  following  are  reliable  : 

^i     Orthoformi,  5.0  grammes ; 

lodoformi,  10.0         " 

Ol.  olivffi,  100.0         " 

Sig. — Shake  and  use  5  to  15  c.c. 

^      Orthoformi,  5.0  grammes ; 

lodoformi,  10.0         " 

Gummi  tragacanthse,         1.0  gramme; 
Glycerini,  q.  s.  ad  100.0  grammes. 

Sig. — Shake  and  use  from  5  to  15  c.c. 

In  irrigating  the  bladder,  the  kind  of  catheter  to  be  used 
and  the  technique  of  flushing  depend  upon  the  cause.  If  it 
is  a  case  of  hypertrophy  of  the  prostate,  a  large  (22  Ch.) 
catheter  may  be  used  ;  if  following  a  posterior  urethritis, 
usually  a  small  catheter,  etc. 

If  strictures,  stones,  or  tumors  are  present,  these  must  be 


HYPERTROPHY  OF  THE  BLADDER. 


189 


treated  as  are  the  causes  before  any  reasonable  hope  of  curing 
the  inflammation  can  be  had. 

In  chronic  cases  local  therapy  is  the  most  important.  The 
bladder  is  irrigated  with  a  3  per  cent,  boric  acid  solution. 
This  is  followed  later  by  a  1  :  5000  permanganate  of  potas- 
sium solution,  or  eventually  by  flushing  out  with  a  1  :  10,000 
silver  nitrate  solution.     Both  may  be  gradually  increased  to 

1  :  1000.     In  very  stubborn  cases,  or  in  cases  of  granulating 
cystitis,  instillation  must  be  resorted  to,  and  a  few  drops  of  a 

2  to   5  per   cent,    silver  nitrate    solution   applied  with   the 
Guyon  instillator. 

Ulcers  of  the  bladder  are  curetted  and  cauterized  by  the 
aid  of  the  operative  cystoscope. 

Parenchymatous  cystitis  and  cystitis  dolorosa  call  for  per- 
manent drainage  and  rest  of  the  bladder  by  establishing  a 
perinea]  or  suprapubic  fistula,  and  by  inserting  a  drainage- 
tube  into  it,  so  that  the  bladder  may  be  regularly  flushed  out 
with  antiseptic  solutions,  and  also  put  at  physiological  rest 
by  allowing  no  urine  to  collect  in  it. 


DlFFEEENTIAL   DIAGNOSIS   BETWEEN   ACTJTE   AnTEEIOE   AND   POSTEEIOE 

Ueetheitis  and  Ueetheocystitis. 


Disease. 

Two-glass 
method. 

Jadassohn 
irrigation 
method. 

Reaction. 

Albumin. 

Microscopic. 


Bacterial. 


Acute  Anterior   Ure- 
thritis. 

1.  Turbid. 

2.  Clear. 
Clear. 


Acid. 
Negative. 

Second  -  glass  sedi- 
ment negative. 


Gonococci. 


.ieiite  Posterior 
Urethritis. 

1.  Turbid. 

2.  Turbid  or  clear. 
Turbid  or  clear  or 

specks. 

Acid. 

Negative.  Occa.sion- 
ally  a  slight  trace. 
Pus-cells. 
Few  epithelial  cells. 


Gonococci. 


:  first  glass  of  the  Thompson  two-glass  test. 
■  second  glass  of  the  Thompson  two-glass  test. 


Acute  or  Chronic 
Urethrocystitis. 

1.  Turbid. 

2.  Turbid. 
Turbid. 


Acid,  often  alkaline. 
Usually  positive. 

Pus-cells. 

Epithelia  of  bladder  and 
posterior  urethra  of  va- 
rious shapes. 

Rarely  gonococci,  but  often 
streptococci. 


Hypertrophy  of  the  Bladder. 

This   is  cau.sed  by  a  chronic  cystitis,  and   is  readily  diag- 
nosticated.    Examination  with  a  sound  gives  this  impression 


190    MALFORMATIONS,  INJURIES,  DISEASES  OF  BLADDER. 

to  the  sense  of  touch.  The  bimanual  examination  reveals 
the  tumor-like  mass.  In  these  cases  of  concentric  hyper- 
trophy the  capacity  of  the  bladder  is  usually  decreased,  and 
but  a  small  quantity  of  retention  is  found.  It  is  impossible 
to  inject  large  quantities  of  fluid  on  account  of  causing  severe 
pain. 

Neoplasms  of  the  Bladder. 

Tumors  of  the  bladder  are  either  primary — by  which  is 
meant  that  they  develop  from  the  bladder — or  secondary, 
either  derived  by  direct  extension  from  neighboring  organs, 
as  from  the  prostate  gland,  or  are  metastatic.  The  latter  two 
varieties  are  most  often  malignant  in  character. 

Tumors  in  the  bladder  may  be  either  benign  or  malignant. 
The  former  are  fibromata,  or,  in  rare  instances,  myomata  or 
angiomata.  Once  in  a  while  cysts  may  be  observed,  which 
may  be  either  simple  cysts  or  dermoids. 

Benign  Tumors. 

The  most  common  of  these  are  papillomata — fibroma papil- 
lare.  These  are  villous  excrescences  which  float  around  in 
the  bladder  fluid,  resembling  in  their  appearance  certain  kinds 
of  sea- weed.  Although  not  malignant,  they  show  a  marked 
tendency  to  recurrence.  They  may  cover  the  larger  or  even 
the  entire  surface  of  the  bladder,  and  are  found  especially  in 
the  fundus,  and  then  within  the  trigonum  ;  or  they  appear  as 
one  large  growth,  overshadowing,  mushroom-like,  on  a  single 
pedicle.  In  rare  instances  these  papillomatous  growths  do 
not  show  any  signs  of  malignancy  in  their  free  part,  while 
the  base  is  cancerous. 

Malignant  Tumors. 

Varieties. — Those  observed  in  the  bladder  are  cancroids,  sar- 
comata, and  myxomata.  These  malignant  tumors  have  a  ten- 
dency to  ulcerate  on  their  surface,  thus  producing  cystitis  and 
h;rmatnria.  Once  in  a  while  malignant  tumors  appear  in  the 
bladder  as  secondary  growths  in  consequence  of  the  bladder- 
wall  being  involved  in  malignant  tumors  of  adjacent  organs, 


NEOPLASMS  OF  THE  BLADDER.  191 

especially  as  an  extension  from  the  uterus.  The  most  common 
form  of  carcinoma  of  the  bladder,  and  that  having  the  worst 
])rognosis,  is  the  scirrhus.  This  readily  affects  neighboring- 
organs,  and  pyelitis  and  nephritis,  with  accompanying  cachexia, 
rapidly  set  in.  All  in  all,  there  are  more  males  than  females 
attacked  with  tumors  of  the  bladder.  They  occur  at  all  ages, 
but  rather  uncommonly  before  the  thirtieth  year. 

The  subjective  symptoms  of  tumor  of  the  bladder  are  a 
constant  sensation  of  heaviness  in  this  region,  which  sensation 
is  considerably  increased  during  the  night,  on  account  of  the 
congestion  produced  through  the  bed-warmth.  Tumors  about 
the  ureteral  opening  may  cause  compression  of  the  ureters 
and  hydronephrosis.  Papillomata  situated  near  the  bladder 
neck  are  likely  to  produce  pains  in  the  perineum,  with  a  per- 
manent desire  for  urinating.  Malignant  growths  quite  often 
cause  lightning  pains  which  radiate  into  the  penis. 

Objective  symptoms  are  frequent  hemorrhage,  without  any 
previous  mechanical  interference ;  that  is  often  the  first  and 
characteristic  symptom  of  tumor.  The  recurrence  and  con- 
tinuance of  the  hemorrhage  are  the  peculiar  characteristics 
of  bleeding  from  tumors.  This  manner  of  occurrence  is 
almost  pathognomonic  of  tumors.  In  case  of  malignant 
tumors,  where  cystitis  sets  in,  it  is  most  often  of  ammo- 
niacal  type,  and  .in  the  course  of  ulceration  capillaries  are 
eroded;  hence  the  blood  is  mixed  with  the  ammoniacal 
urine.  Malignant  growths  generally  produce  cachexia.  In 
very  favorable  cases  large  tumors  of  the  bladder  may  even 
be  palpated  by  bimanual  examination. 

The  diagnosis  is  made  certain  if  we  find  tumor  particles  in 
the  urine  or  discover  the  mass  by  digital  examination  through 
a  perineal  opening  or  by  cystoscopy.  The  latter  method  may 
be  used  practically  in  all  cases,  and  the  diagnosis  be  thus 
made.     Examination  with  sounds  is  not  to  be  recommended. 

The  treatment  of  all  tumors  may  be  an  operative  one  only. 
Benign  tumors  may  be  removed  by  the  caustic  snare  of  the 
operation  cystoscope,  while  in  the  case  of  malignant  tumors,  a 
radical  extirpation  must  be  performed  after  access  is  gained 
by  suprapubic  cystotomy.     Whenever  the  condition  is  so  fir 


192    MALFORMATIONS,  INJURIES,  DISEASES  OF  BLADDER. 

advanced  as  not  to  allow  of  this,  palliative  treatment  must  be 
instituted — permanent  suprapubic  or  perineal  fistula,  so  that 
the  bladder  can  be  thoroughly  irrigated  and  drained.  Neces- 
sarily, opiates  must  be  given  if  the  pains  are  excruciating. 
Besides,  hemorrhages  and  cystitis  must  also  be  treated  by 
internal  medication  and  local  means,  combining  astringents 
and  antiseptics. 

Foreign  Bodies  of  the  Bladder. 

The  larger  number  of  foreign  bodies  reach  the  bladder  by 
way  of  the  urethra,  and  in  various  manners.  Probably  the 
most  common  are  those  which  are  introduced  at  the  time  of 
masturbation,  again  by  instrumentation  and  by  therapeutical 
agents.  To  avoid  these  accidents  every  instrument  should  be 
closely  examined  previous  to  its  introduction.  Of  course, 
strictures  and  other  obstructions  aid  or  are  often  the  cause  of 
the  mishap.  Foreign  bodies  may  also  reach  the  bladder  by 
way  of  pathological  migration.  Pessaries  causing  pressure- 
necrosis  have  been  found  in  the  bladder  of  women.  Even 
foreign  bodies  from  the  intestinal  tract,  after  agglutination  of 
intestines  with  bladder,  have  been  observed. 

Diagnosis. — The  symptoms  may  be  similar  to  those  of  stone 
— frequent  urination,  with  pains,  hemorrhages,  and  turbid 
urine.  A  sound  may  aid  the  diagnosis,  and  the  cystoscope 
will  verify  it.     The  X-rays  will  often  show  foreign  bodies. 

If  the  objects  are  small,  they  may  be  removed  through  a 
straight  tube  introduced  into  the  bladder,  if  necessary,  placing 
the  patient  in  the  knee-chest  position  and,  with  the  aid  of  an 
operation  cystoscope.  Lithotriptors  have  also  been  used  for 
this  purpose.  If  it  is  impossible  to  remove  them  in  this 
manner,  or  if  it  is  deemed  best  not  to  do  so,  an  operative 
procedure,  such  as  a  suprapubic  operation,  becomes  necessary. 
In  women  most  foreign  bodies  in  the  bladder  may  be 
removed  by  dilating  the  urethra  to  a  diameter  of  f  or  f  inch, 
and  then  digitally  or  instrumentally  manipulating  it  until  the 
objects  present  at  the  neck  for  extraction. 


STONE  IN  THE  BLADDER.  193 

Stone  in  the  Bladder. 

Cause  and  Pathology. — Stoues  in  the  bladder  may  be  formed 
around  a  small  calculus  which  may  have  descended  into  the 
bladder  from  the  kidneys  and  remained  inside  of  the  bladder, 
either  having  been  caught  in  the  trabeculse  or  having  been 
too  large  to  be  voided  in  urination.  In  other  cases  tho 
nucleus  for  the  stone  consists  of  a  coagulum  or  a  particle  of  a 
tumor  or  some  other  foreign  body.  The  tendency  to  the  for- 
mation of  stones,  provided  a  small  foreign  body  is  in  the 
bladder,  is  enhanced  by  stagnation  of  the  urine  and  by  a 
general  diathesis  creating  a  predisposition  to  excessive  pre- 
cipitation of  urinary  solids.  These  precipitated  solids,  accord- 
ing to  the  theory  proposed  by  Ebstein,  are  agglutinated  by  a 
cementing  material  furnished  by  pus,  mucus,  or  some  organic 
substance.  Harris  and  others  have  attempted  to  show  that 
bacteria  are  present  in  all  calculi,  and  they  have  demonstrated 
this  fact ;  they  believe  that  the  bacteria  are  the  beginning  of 
the  process  of  stone  formation. 

As  a  rule,  stones  are  formed  of  the  phosphates  and  urates, 
and  occasionally  of  the  carbonates,  in  the  urine.  In  other 
cases  they  are  formed  of  chemical  constituents  which  are 
separated  from  the  blood  by  the  kidneys,  but  only  under 
certain  abnormal  conditions.  Such  stones  may  be  formed  by 
oxalate  of  lime  or  by  cystine.  Climatic  and  atmospheric 
conditions,  drinking-water,  and  wines  have  been  regarded  as 
important  factors  in  the  formation  of  stones.  Heredity  is 
regarded  as  taking  part,  since  entire  families  have  been  shown 
to  suffer  from  cystine  stones. 

It  is  not  an  infrequent  occurrence  that  a  stone  consists  of 
different  layers,  which  have  various  chemical  composition,  and 
have  been  precipitated  under  different  conditions  of  the  urine. 
On  section,  such  stones  have  the  appearance  of  concentric 
layers.  While  uric  acid  stones  and  phosphatic  stones  show 
smooth  surfaces,  oxalate  of  lime  stones  have  a  rough  surface, 
which  gives  them  the  name  of  mulberry  stones.  Stones  are 
more  commonly  found  in  children  and  in  those  of  advanced 
age  than  at  middle  age,  and  in  men  more  frequently  than  in 
13— v.  D. 


194    MALFORMATIONS,  INJURIES,  DISEASES  OF  BLADDER. 

women.  This  is  probably  explained  by  the  fact  that  the 
urethra  in  woman  is  so  dilatable  as  to  pass  out  many  stones 
as  soon  as  they  appear.  While  phosphatic  calculi  are  formed 
only  in  the  bladder,  urates  and  oxalates  are  first  formed  in 
the  kidney. 

The  shape  of  bladder  stones  is,  as  a  rule,  that  of  an  egg  or 
a  small  globe.  The  size  varies  from  that  of  a  pea  to  one 
which  completely  fills  the  bladder.  The  number  of  stones 
that  may  be  present  is  also  very  variable.  If  a  large  number 
of  stones  accumulate  in  one  bladder,  they  may  become  faceted 
by  rubbing  against  one  another.  The  increase  in  the  size  of 
stone  differs  according  to  individual  conditions  and  with  the 
kind  of  stone  formation.  Phosphates  increase  in  size  most 
rapidly;  oxalates  and  urates  much  more  slowly.  Usually 
there  is  a  progressive  enlargement.  They  may  be  either  free 
in  the  cavity  or  fixed — i.  e.,  may  be  situated  in  a  diverticulum. 

Symptoms. — The  presence  of  stones  in  the  bladder  produces 
the  following  symptoms  :  The  patient  may  have  a  sensation 
as  of  a  foreign  body  in  his  bladder,  which  may  become  a 
distinct  pain.  He  notices  pains  in  violent  movements,  espe- 
cially when  being  shaken  in  taking  a  ride  on  a  bad  road,  or 
whenever  jarred  in  any  manner.  Rest  in  bed  in  these  un- 
complicated cases  gives  partial  immediate  relief,  in  contra- 
distinction to  pains  caused  by  other  diseases ;  therefore,  when 
complicated  with  cystitis  or  ulcer,  the  pains  do  not  necessarily 
disappear  at  once  with  rest.  Hemorrhage  may  occur  during 
such  violent  motions.  Whenever  stone  is  complicated  with 
hypertrophy  of  the  prostate,  tumors,  or  cystitis,  hemorrhage 
may  occur  during  periods  of  rest,  and  not  uncommonly  after 
excessive  sexual  excitement  or  following  errors  in  diet.  It 
is  quite  a  frequent  occurrence  that  the  urinary  stream  is 
suddenly  interrupted,  and  begins  again  after  the  patient  has 
displaced  a  calculus  from  the  internal  urethral  orifice  by 
certain  movements.  In  time,  stones  with  rough  surfaces 
produce  traumatic  lesions  of  the  bladder  mucosa,  so  that  con- 
stant pain  results,  which  almost  always  radiates  into  the 
penis  or  scrotum,  and  is  present  in  most  of  the  cases.  If  the 
stone  becomes  fixed  in  the  internal  urethral  orifice,  it  may 


STONE  JN  THE  BLADDER.  195 

cause  acute  retention  of  urine.  Practically  in  all  cases  there 
is  increased  frequency  of  urination,  especially  noticeable  when 
the  patient  is  up  and  about  and  lessened  when  resting.  Occa- 
sionally, small  fragments  of  stone  are  passed  with  the  urine. 
In  almost  every  case  blood  is  present,  at  least  in  microscopic 
quantities. 

Diagnosis. — Sounding. — In  order  to  diagnose  a  stone,  the 
bladder  is  searched  by  a  steel  sound  with  a  very  short  beak. 
This  short  beak  allows  of  very  free  movements  inside  of  the 
viscus,  so  that  every  part  of  the  bladder  may  be  explored 
satisfactorily.     It  is  best  to  have  the  patient  on  his  back  and 

Fig.  15. 


stone  searcher  or  sound. 


the  bladder  tilled  with  about  100  c.c.  of  distilled  water.  In 
order  to  demonstrate  quite  distinctly  the  metallic  click  which 
is  produced  by  contact  of  the  stone  with  a  sound,  it  is  best 
to  use  sounds  which  are  fitted  at  their  handle  with  a  so-called 
resonator,  a  short,  hollow,  metallic  tube  with  very  thin  walls. 
By  passing  the  beak  of  the  sound  in  different  directions  over 
the  now  detected  stone,  a  fair  estimate  may  be  made  of  its 
size  and  surface.  This  examination  may  be  completed  by 
following  it  with  cystoscopy,  which  is  especially  instructive 
in  cases  of  multiple  stones  or  in  cases  in  which  the  stone  is 
firmly  embedded  in  a  diverticulum. 

Palpation,  especially  by  the  vagina  in  women,  may  reveal 
a  stone.  In  the  male,  especially  when  there  is  a  hypertro- 
phied  prostate,  stones  cannot  usually  be  felt.  If  a  stone  of 
enormous  size  is  present,  it  can  be  palpated  through  the  lax 
abdominal  walls,  especially  if  a  finger  is  inserted  in  the 
rectum  and  exerts  pressure  upward. 

Skiagraphy  should  be  employed,  as  it  often  gives  the  cor- 
rect number  and  size  of  stones. 

Treatment. — There  are  three  methods  of  removing  stones 


196    MA  LFOBMA  TIONS,  IN  J  URIES,  DISEA  SES  OF  BLA  DDER. 

from  the  bladder.  Very  small  stones  may  be  pumped  out 
by  using  an  evacuation  catheter  and  a  Bigelow  pump.  Large 
stones  either  may  be  crushed  inside  of  the  bladder  and  the 
debris  pumped  out  afterward  (litholapaxy),  or  may  be  re- 
moved after  the  bladder  is  opened  by  perineal  or  suprapubic 
incision  (lithotomy). 

The  internal  treatment  with  the  object  of  dissolving  or 
causing  dissolution  of  the  stone — i.  e.,  litholysis — is  without 
result. 

The  prophylactic  treatment,  however,  is  not  to  be  forgotten. 
In  cases  of  uratic  stones,  alkaline  mineral  waters,  naixed  diet, 
with  as  little  carbohydrate  food  as  possible,  and  in  cases  of 
oxalate  stones  an  animal  diet,  should  be  ordered.  It  fre- 
quently becomes  necessary,  besides,  to  treat  symptomatically, 
whenever  hemorrhages,  pains,  or  tenesmus  are  present,  in  the 
manner  already  described  elsewhere. 

Litholapaxy  is  always  to  be  employed  if  the  conditions  for 
its  execution  exist.  These  conditions  are :  the  urethra  must 
be  permeable  for  the  lithotriptor  and  the  large  evacuating 
catheters.  The  stone  must  be  small  enough  to  allow  of 
sufficiently  large  space  between  the  stone  and  the  bladder- 
walls,  so  that  the  blades  of  the  lithotriptor  can  easily  be 
manipulated.  The  stone  must  be  freely  movable  inside  of 
the  bladder,  and  should  not  be  extremely  hard. 

Perineal  lithotomy  is  to  be  used  only  in  cases  of  small 
stones  and  where  the  number  of  concretions  is  known  posi- 
tively, because  it  is  impossible  to  explore  the  entire  bladder 
with  certainty  through  a  perineal  incision. 

Suprapubic  lithotomy  must  be  resorted  to  in  all  other  cases. 

Litholapaxy. 

The  instruments  necessary  for  performing  lithotripsy  are  : 
first,  the  lithotriptor,  or  crusher,  and,  secondly,  the  evacuator 
— that  is,  the  instrument  for  pumping  out  the  crushed  frag- 
ments from  the  bladder.  The  lithotriptor  consists  of  two 
blades  whose  ends  are  bent  at  almost  a  right  angle.  These 
blades  fit  into  each  other,  so  that  when  closed  the  instrument 


LITHOLAPAXT. 


197 


resembles  a  simple  sound.  The  larger  blade  is  perforated  and 
is  called  the  female  blade,  while  the  smaller  blade  carries  at 
its  beak  a  roughened  surface,  so  that  when  the  stone  is  caught 
between  these  blades  by  forcibly  bringing  them  together  it 
maybe  crushed.  The  two  blades  can  be  made  fast  at  diiferent 
distances  by  a  rack  and  pinion  at  the  handle.  The  crushing 
itself  is  performed  by  forcing  the  two  blades  together  through 
the  screw  which  is  hidden  in  the  shaft. 

The  evaeuator  consists  of  a  glass  bulb  on  the  top  of  which 
a  rubber  balloon  is  attached.  This  rubber  carries  two  cocks 
— one  close  to  the  glass  bulb  and  the  other  on  the  top  of  the 

Fig.  16. 


Lithotrite. 


glass  balloon.  After  the  balloon  and  the  bulb  are  filled  with 
water,  the  lower  cock  is  attached  to  the  evacuating  catheter, 
while  the  upper  cock  is  closed.  If  the  rubber  balloon  is  com- 
pressed, it  forces  the  contents  into  the  bladder.  If  the  pres- 
sure in  the  balloon  is  relieved,  it  will  expand  and,  by  suction, 
produce  a  rush  of  water  from  the  bladder  which  will  carry 
away  the  crushed  fragments.  These,  on  account  of  their 
higher  specific  gravity,  will  sink  down  into  the  glass  bulb. 
If  the  compression  is  maintained  and  the  balloon  in  turn 
relieved,  all  the  fragments  from  the  bladder  will  be  removed. 
In  order  to  perform  lithola]iaxy,  the  patient  is  prepared  in 


198    MALFORMATIONS,  INJURIES,  DISEASES  OF  BLADDER. 
Fig.  17.  Fig.  19. 


Fig.  18. 


Lithotrites  or  stone-crushers.  From  left  to  right  in  serial  order  are  the  blades 
opened,  the  instrument  assembled  with  blades  closed,  the  female  blade  and  the 
male  blade  separate. 


LITHOLAPAXY. 


199 


the  following  way  :  An  existing  cystitis  is  treated  by  irriga- 
tions ;  previous  to  the  operation  a  urinary  antiseptic  is  admin- 
istered. In  order  to  make  the  urethra  as  flexible  and  patulent 
as  possible,  a  large  soft  catheter  is  inserted  in  the  urethra  and 
retained  for  twenty-four  hours  previous  to  the  operation.  As 
a  rule,  litholapaxy  is  performed  under  general  anaesthesia. 
In    tolerant    patients   a   local   ansesthesia   (4  per  cent,    anti- 


Evacuator  for  the  removal  of  fragments  from  the  bladder. 

pyrin)  will  suffice.  From  25  to  50  c.c.  of  a  3  to  5  per  cent, 
antipyrin  solution  are  put  into  the  bladder  and  allowed  to 
remain  from  ten  to  twelve  minutes;  this  is  then  replaced 
with  100  c.c.  of  a  saturated  boric  acid  solution.  Meanwhile 
a  0.01  gra.  morphine  suppository  is  introduced  into  the  rectum, 
and  sufficient  eucaine  solution  to  ansesthetize  the  urethra  is 
applied.     Patients  who  have  had  litholapaxy  performed  re- 


200    MALFOBMATIONS,  INJURIES,  DISEASES  OF  BLADDER. 

peatedly  upon  them  become  so  tolerant  that  these  operations 
may  be  performed  without  any  general  or  local  anaesthesia. 
The  patient  is  placed  in  a  recumbent  position,  his  pelvis 
somewhat  elevated  in  order  to  secure  free  manipulation  of  the 
instrument.  Into  the  bladder  as  much  sterile  water  is  injected 
as  possible,  without  hyperdistention  of  the  bladder;  then  the 
closed  lithotriptor  is  introduced,  and  after  the  stone  is  found 
the  blades  are  separated.  By  different  movements  an  attempt 
is  made  to  secure  the  stone.  After  this  is  done,  the  blades 
are  arrested,  and  the  beak  is  made  to  turn  freely,  in  order  to 
demonstrate  that  a  mucous  fold  has  not  been  caught.  Now, 
by  screwing  the  blades  together  the  seized  stone  is  crushed. 
It  is  necessary  now  to  release  the  blades,  open  them  again, 
pick  up  one  of  the  fragments,  crush  it,  and  the  process  re- 
jieated  until  no  large  fragments  can  be  detected.     In  order  to 

Fig.  21. 


stone  forceps. 


pulverize  the  small  fragments  some  operators  prefer,  after  the 
stone  is  divided  into  fragments,  to  remove  the  instrument  and 
to  introduce  another  lithotriptor  whose  female  blade  is  not 
perforated.  This  latter  instrument  is  called  a  ramasseur. 
After  a  litholapaxy  has  been  performed  it  is  a  good  plan  to 
examine  the  bladder  by  means  of  the  cystoscope  in  order  to 
ascertain  whether  any  fragments  remain  in  the  bladder,  or 
whether  fragments  embedded  in  the  bladder-wall  are  to  be 
seen.  If  this  is  the  case,  they  are  removed  by  the  forceps  of 
the  operation  cystoscope.  It  is  very  important  to  remove  all  the 
fragments  in  one  sitting,  in  order  to  avoid  secondary  compli- 
cations, as  traumatism  from  sharp  splinters  and  secondary  cys- 
titis. There  are  cases  on  record  in  which  such  a  sharp  splinter, 
by  perforating  the  bladder-wall,  caused  a  fatal  pericystic 
phlegmon. 


MEDIAN  LITHOTOMY. 


201 


If  the  bladder- wall  is  not  injured  during  the  operation, 
there  will  be  no  subsequent  hemorrhage.  It"  the  bladder  is 
the  seat  of  dilated  veins,  there  might  be  a  hemorrhage  after 
the  operation.  In  these  cases  the  bladder  is  flushed  M'ith 
1 :  10,000  to  1  :  1000  silver  nitrate  solution  until  the  bleeding 
ceases.  A  permanent  catheter  is  inserted  until  the  bloody 
hue  of  the  urine  entirely  disappears. 

Regarding  tJie  perineal  operations,  onh/  the  median  lithotomy 
is  to  be  commended.  The  lateral  section,  so  popular  in  former 
times,  is  nowadays  abandoned  because  of  its  many  inconveniences 
and  dangers.      This  is  also  true  of  the  bilateral  operation. 

Median  Lithotomy. 

In  its  preliminary  steps  this  is  identical  with  perineal  ure- 
throtomy, and  the  description  of  the  latter  will  therefore  suffice. 

Fig.  22. 


Psychrophor. 

For  removing  the  stones,  curved  forceps  of  various  shapes 
are  used.  As  the  opening  into  the  bladder  is  comparatively 
small,  all  stones,  especially  if  large  and  if  they  have  rough 
surfaces,  should  not  be  removed  before  crushing  them  pre- 
viously with  lithotriptic  forceps  or  forceps  made  for  this 
purpose.  The  after-treatment  of  perineal  operations  is  occa- 
sionally complicated  by  inflammation  around  the  neck  of  the 
bladder,  and  eventually  secondary  suppurations  may  take 
place.     Furthermore,  bruising  or  even  laceration  of  the  pros- 


202     MALFORMATIONS,  INJURIES,  DISEASES  OF  BLADDER. 

tate  and  ducts  has  been  observed.  As  regards  the  after- 
treatment,  especially  if  small  particles  are  believed  to  have 
remained  in  the  bladder,  a  large  drainage-tube  may  be  allowed 
to  remain  for  a  few  days.  In  this  manner  the  bladder  may 
be  irrigated  frequently.  In  rare  cases  the  perineal  opening 
becomes  transformed  into  a  permanent  fistula,  which  may  be 
cured  by  cauterization,  or  in  stubborn  cases  by  freshening  and 
suturing  the  lips  of  the  fistula,  and  then  inserting  a  catheter 
through  the  urethra,  which  should  be  made  permanent  until 
the  fistula  closes. 

Suprapubic  Cystotomy. 
The  patient  is  placed  in  a  recumbent  position,  and  the 
pelvis  is  somewhat  elevated.  Under  complete  ansesthesia,  a 
catheter  is  introduced  into  the  bladder,  and  this  organ  is 
washed  out  until  the  fluid  returns  quite  clear.  Then  the 
bladder  is  distended  by  the  injection  of  about  150  c.c.  of 
sterile  Avater,  and  the  penis  tied  oiF  by  means  of  a  strip  of 
gauze.  The  incision  is  now  made,  starting  just  above  the 
symphysis,  and  conducted  upward  in  the  median  line  from 
li-  to  3  inches.  The  fat  is  split  until  the  linea  alba  is 
reached.  This  is  severed,  and  the  recti  muscles  separated. 
Thus  the  so-called  space  of  Retzins  is  opened.  The  pre- 
vesical fat,  which  now  appears,  is  stripped  from  the  bladder, 
and  the  wall  of  the  bladder  presents  itself  in  the  wound  ; 
it  may  be  recognized  by  its  brown  color,  the  trabeculse,  and 
the  large  veins  which  run  over  its  surface.  In  the  upper 
angle  of  the  wound,  resembling  a  blue  half-globe,  appears 
the  peritoneal  fold.  In  case  of  necessity  the  peritoneum  is 
pushed  upward  and  retained  by  a  small  blunt  retractor. 
After  this  the  bladder-wall  is  seized,  just  underneath  the 
peritoneal  fold,  with  a  tenaculum.  Now  the  bladder  is 
opened  by  passing  a  sharp  bistoury  underneath  the  tenac- 
ulum into  the  bladder  cavity,  and  Gutting  clown  toward  the 
symphysis.  The  fluid  contained  in  the  bladder  overflows  the 
operating  field  and  is  sponged  off,  and  lateral  retractors  are 
inserted  into  the  bladder,  thus  separating  the  incised  wound 
and  rendering  the  interior  of  the  viscus  accessible.     Stones 


CONTINUOUS  VESICAL  DRAINAGE.  203 

may  be  removed  by  certain  kinds  of  spoons  or  forceps.  In 
uncomplicated  cases  there  is  no  objection  to  closing  the  blad- 
der with  two  layers  of  catgut  sutures.  The  prevesical  space 
should  not,  even  in  such  cases,  be  closed  entirely,  but  left 
open  far  enough  to  allow  of  loose  packing  until  the  primary 
reunion  of  the  bladder  wound  has  been  established.  If 
closure  of  the  bladder  is  not  desired,  the  bladder  wound  is 
only  partly  sutured,  so  that  in  its  centre  a  drainage-tube 
which  reaches  into  the  has  fond  may  be  inserted  and  a  purse- 
string  suture  drawn  around  it,  in  order  to  prevent  leakage 
of  urine. 

The  external  incision  is  now  closed  at  its  angles  by  a  few 
stitches,  and  the  prevesicular  space  and  edges  slightly  packed 
with  gauze ;  then  the  drainage-tube  is  connected  to  a  small 
glass  tube  which  is  bent  at  a  right  angle.  To  the  other  end 
of  the  glass  tube  a  rubber  hose  is  attached,  which  dips  into 
a  bottle  which  is  filled  with  an  antiseptic  solution.  This 
drainage  is  continued  until  the  entire  w^ound  is  covered  with 
healthy  granulations.  Some  operators  prefer  to  fasten  the 
bladder  to  the  abdominal  incision  with  a  few  stitches  after 
each  cystotomy.  If  the  cystotomy  is  made  in  order  to  per- 
form endovesical  operations,  as  for  tumors,  etc.,  three  retract- 
ors are  inserted  into  the  bladder — two  small  lateral  ones  and 
a  large  Simon's  speculum  into  the  upper  angle  of  the  wound. 
The  after-treatment  is  the  same  as  that  previously  described. 
If  it  is  desired  to  establish  a  permanent  fistula,  the  bladder- 
wall  is  fastened  by  sutures  to  the  anterior  abdominal  wall,  so 
that  the  bladder-wall  grows  in  immediate  contact  with  the 
abdominal  walls.  The  length  of  time  required  in  order  to 
obtain  good  results  varies  as  to  the  presence  or  not  of  com- 
plications. In  some  cases  it  may  be  necessary  to  permit  the 
suprapubic  tube  to  remain  for  from  one  to  three  weeks  or  even 
longer,  depending  upon  the  condition  of  the  bladder  and  the 
state  of  the  urine. 

Continuous  Vesical  Drainage. 
Continuous  drainage  of  the  bladder  is  easily  and  perfectly 
secured  by  using  the  apparatus  of  R.  H.  M.  Dawbarn,  of 


204    MALFORMATIONS,  INJURIES,  DISEASES  OF  BLADDER. 

New  York,  which  is  practically  a  Sprengel  pump,  except 
that  the  intermittent  action  is  by  water  instead  of  by  mer- 
cury. A  large  catheter  (30  to  40  French)  is  inserted  into  the 
base  of  the  bladder,  and  at  the  wound  is  surrounded  by  a 
short  piece  of  large  rubber  tubing,  so  that  the  atmospheric 
])ressure  can  pass  between  them  into  the  viscus.  The  cath- 
eter is  now  attached  to  a  piece  of  rubber  tube  which  meets 
in  a  Y-tube  the  outflow  from  the  reservoir  at  a  point  below 
the  level  of  the  bladder  floor  as  the  patient  lies  in  bed.  A 
common  douche-bag  is  an  excellent  reservoir.  The  exit  of 
the  Y-tube  has  a  tube  attached  to  it  leading  into  the  recep- 
tacle of  antiseptics  below  the  bed,  and  trapped  by  tying  a 
knot  loosely  in  it.  When  the  trap  fills,  it  empties  itself  and 
thus  siphons  away  the  urine  in  the  bladder,  which  should 
occur  once  in  about  five  minutes.  Urine  for  examination 
and  measuring  can  be  obtained  by  putting  a  wash-bottle  into 
the  circuit  between  the  Y-tube  and  the  bladder,  with  the 
long  tube  of  the  bottle  toward  the  bladder. 

A  Chemical  Analysis  of  the   Stones. — This  can   be  made 
quickly.     An  outline  is  as  follows  : 


Combustible. 


XON- 
COMBUSTIBLE. 


The  stone  after  it  is 
powdered  burns, 
after  placing  on  a 
platinum  dish , 
without  giving  off 
a  flame  or  odor. 


Murexid  test :  With  ammonia, 
purplish  red  ;  with  potas- 
sium hydrate,  purplish 
violet. 
Murexid  test :  With  ammonia, 
yellow;  with  potassium  hy- 
drate, orange  yellow. 
The  powder,  on  being  placed  on  a  platinum  dish, 
burns,  giving  a  bluish  flame,  and  emitting  an 
odor  of  sulphur. 

On  the  addition  of  hydrochloric  acid  to  the  pow- 
dered stone  there  is  an  effervescence. 

The  ash  of  the  stone  eflFer- 
vesces  with  hydrochloric 
acid. 
The  ash  of  the  stone  does 
not  effervesce  with  the 
addition  of  hydrochloric 
acid. 


No  effervescence  by 
the  addition  of  hy- 
drochloric acid  to 
the  stone. 


Uric  acid  and 
uric  acid 
salts. 


Xanthin. 
Cystin. 


Carbonate  of 
lime. 


Oxalate  of 


lime. 


Phosphates. 


Neuroses  of  the  Bladder. 

Neuroses  of  the  bladder  are  regarded  as  nervous  conditions 
per  se  which  affect  the  bladder,  in  either  disturbances  of  sen- 


SPASM  OF  THE  BLADDER.  205 

sibility  or  motility,  and  manifest  themselves  as  spasms  or 
paralyses.  No  central  or  cord  affections  involving  the  bladder 
are  to  be  considered  strictly  under  this  particular  heading. 

Previous  to  making  a  diagnosis,  every  known  method  of 
examination,  especially  cystoscopy,  should  be  used.  Since 
cystoscopy  has  been  employed  it  has  been  demonstrated  that 
small  ulcers  of  the  bladder  were  the  cause  of  symptoms 
resembling  neuroses,  hence  they  were  not  a  neurosis,  and 
thereby  showed  the  necessity  of  thus  examining. 

Spasm  of  the  Bladder. 

Spasmus  vesicae,  cystospasmus,  is  a  spasm  of  the  bladder, 
regarded  as  caused  by  a  hypersensitive  condition  of  the 
bladder  nerve-endings,  which  condition  causes  repeated  mus- 
cular contractions.  Small  quantities  of  urine  cause  contrac- 
tion and  tenesmus,  so  that  either  or  both  the  detrusor  and 
sphincter  muscles  are  called  into  action.  It  is  impossible  to 
distinguish  one  from  the  other.  In  these  cases  the  mucous 
membrane  of  the  bladder  is  perfectly  normal,  and  the  urine 
without  any  pathological  elements.  The  pain  is  most  severe 
when  the  bladder  empties  itself.  A  feeling  of  spasm  coexists, 
and  may  radiate  to  the  penis  or  testes.  In  connection  with 
this  subject  all  other  affections  which  might  act  reflexly  must 
be  excluded — i.  e.,  anal  and  rectal  diseases,  and  especially,  in 
icomen,  those  involving  the  internal  genitalia.  If  no  patho- 
logical cause  in  the  bladder  can  be  found,  the  condition  is 
what  is  correctly  known  as  irritable  bladder,  or  occasionally 
termed  cystalgia.  The  attacks  may  last  a  few  minutes  or 
even  longer,  and  repeat  themselves  frequently,  or  hours  may 
intervene. 

In  the  treatment  it  is  necessary  to  correct  anything  that 
causes  a  reflex  action.  In  these  cases  excesses  of  all  kinds 
should  be  prohibited.  During  the  attack  baths,  narcotics, 
and  especially  a  hypodermic  injection  of  morphine  often 
becomes  a  necessity.  Local  treatment,  such  as  sounds  and 
instillations,  has  apparently  given  good  results  in  selected 
cases. 


206    MALFORMATIONS,  INJURIES,  DISEASES  OF  BLADDER. 

Atony  of  the  Bladder. 

Atony  is  a  muscular  debility  which  is  due  to  exhaustion 
of  the  muscular  coat  of  the  bladder.  This  is  often  caused 
by  the  changes  of  advanced  life  or  is  the  result  of  continual 
overstretching  of  the  detrusor  muscles.  This  overstretching 
may  be  caused  by  some  obstruction  in  the  urinary  passage  or 
by  regular  overdistention  of  the  bladder  due  to  artificial 
strain  in  consequence  of  not  responding  in  time  to  urinary 
calls.  It  is  an  eccentric  hypertrophy  of  the  muscular  coating. 
If  the  atony,  combined  with  a  tight  stricture,  exists  for  any 
length  of  time,  the  phenomenon  appears  which  is  called 
paradoxical  incontinence.  Although  the  bladder  is  unable  to 
empty  itself  by  contraction,  it  constantly  overflows,  because 
after  the  limit  of  its  capacity  is  reached,  every  additional 
quantity  of  urine  flowing  down  from  the  kidneys  causes  an 
equal  quantity  to  dribble  out. 

The  exact  diagnosis  of  atony  is  made  by  introducing  a 
catheter.  The  stream  in  which  the  urine  flows  has  no  force, 
and  drops  from  the  end  of  the  catheter  only  by  the  force  of 
gravity. 

The  treatment  of  atony  has  for  its  first  object  relief  of  the 
overstretched  bladder  muscles  by  catheterization  regularly 
three  or  four  times  a  day,  or  oftener  if  necessary.  Further- 
more, an  attempt  is  made  to  stimulate  the  muscles  by  the 
use  of  electricity  and  by  applying  cold  externally  to  the 
hypogastrium.  If  an  obstruction  produces  the  condition  of 
atony  it  is  of  paramount  importance  to  remove  it. 

Paralysis  of  the  Bladder. 

This  is  the  complete  inability  of  its  muscular  coats  to 
contract,  which  condition  is  due  to  morbid  afiections  of  the 
nervous  centres,  trunks,  or  terminals.  It  may  either  be 
permanent,  in  case  the  causal  nervous  disease  is  permanent, 
or  it  may  be  only  temporary,  if  it  is  caused  by  some  acute 
febrile  nervous  affection,  and  then  subsides  with  its  disap- 
pearance.    The   urine,  as   a  rule,  becomes   decomposed   by 


ENURESIS.  207 

stagnation,  while  the  trophic  disturbances  enhance  the  estab- 
lishment of  crystals. 

The  treatment,  if  it  is  impossible  to^  remove  the  central 
cause,  can  be  only  a  symptomatic  one.  The  urine  is  drawn 
at  regular  intervals  by  the  catheter,  and  antiseptic  washings 
of  the  bladder  are  employed.  If  the  bladder  has  been  dis- 
tended for  a  long  time,  it  is  best  not  to  empty  it  at  once  by 
catheterization,  or  if  the  urine  is  drawn  off  entirely,  the 
bladder  must  be  instantly  partially  filled  with  mild  anti- 
septics, in  order  to  avoid  hemorrhage  ex  vacuo.  If  paralysis 
involves  the  sphincter  muscle,  true  incontinence  occurs. 

Enuresis. 

Whenever  there  is  involuntary  urination  in  an  otherwise 
apparently  normal  bladder,  it  is  regarded  as  a  neurosis.  It 
occurs  most  commonly  in  children,  especially  in  boys  and 
during  the  sleeping  hours.  This  nightly  "  wetting  the  bed  " 
is  called  enuresis  nodurna.  It  is  believed  by  certain  authori- 
ties to  be  due  to  an  underdevelopment  of  the  prostate  and 
external  sphincter  muscle  of  the  bladder  ;  also  reflexly  to 
phimosis,  excessively  long  foreskin,  etc.  In  certain  cases  it 
occurs  during  the  day, — while  laughing,  running,  or  while 
indulging  in  other  physical  exercise, — and  is  then  called 
enuresis  diurna. 

Treatment  consists  in  attempting  to  rectify  the  cause,  if  it 
can  be  found.  If  there  is  phimosis  or  long  foreskin,  circum- 
cision has  given  apparent  relief.  Again,  massage  of  the 
posterior  urethra  given  by  the  rectum  has  been  followed  by 
good  results.  If  individuals  are  undeveloped,  tonics,  baths, 
and  electrical  treatment  may  be  of  service. 

A  very  serviceable  course  of  treatment  for  purely  nervous 
enuresis  nocturna  is  the  following :  Have  the  child  evacuate 
the  bladder  just  before  getting  into  bed,  and  refuse  it  all 
fluids  for  several  hours  (four  to  five)  prior  to  bedtime.  Raise 
the  foot  of  the  bed  several  feet,  best  to  the  top  of  a  table,  so 
that  the  urine  as  delivered  from  the  ureters  into  the  bladder 
will  collect  at  the  fundus  first  and  not  at  the  neck.     In  the 


208    MALFORMATIONS,  INJURIES,  DISEASES  OF  BLADDER. 

Vanderbilt  Clinic   in  New  York,  a  great   number  of  cases 
have  been  found  to  yield  to  the  following  simple  formula  : 

I^     Fluid  extract  ergot, 

Bromide  soda, 

Tinct.  belladonna,  aa  10.0  grammes ; 

Cinnamon- water,  q.  s.  ad  100.0        " 
M.    Mixture  for  enuresis. 
Sig. — One    drachm   three   times  daily  after  meals. 

The  strength  of  this  solution  must  be  reduced  for 

children  less  than  five  years  old. 

QUESTIONS   ON   MALFOEMATIONS,    INJURIES,   AND   DISEASES   OF 
THE  BLADDEE. 

What  is  meant  by  ectopia  vesicai  ? 

What  is  the  treatment  ?     What  is  meant  by  Maydl's  operation  ? 

What  is  meant  by  hernia  of  the  bladder  ? 

What  varieties  are  there?  What  is  their  cause?  What  are  the  symptoms  ? 
How  would  you  treat  the  condition? 

What  is  a  cystocele  ? 

How  may  injuries  of  the  bladder  occur? 

What  classes  are  there  for  practical  purposes  ? 

How  is  it  possible  to  make  the  immediate  diagnosis  of  these  two  classes? 
If  possible,  why  should  a  catheter  not  be  used  ? 

How  is  the  diagnosis  made  twenty-four  hours  after  the  injury? 

What  is  the  prognosis  ? 

What  is  the  treatment  ?     Describe  the  operative  interference? 

What  is  a  fistula  of  the  bladder? 

What  is  meant  by  cystitis  ? 

What  is  meant  by  pericystitis  ? 

What  is  the  origin  of  cystitis  ? 

What  are  the  more  common  predisposing  causes? 

What  are  the  symptoms  of  acute  cystitis? 

How  do  the  different  etiological  types  characterize  themselves? 

What  is  especially  characteristic  of  the  symptoms  of  tuberculous  cystitis? 

If  pus  and  albumin  are  present  in  the  urine,  how  is  the  quantity  of  the 
latter  accounted  for? 

What  are  the  symptoms  of  a  chronic  cystitis? 

Are  ulcers  of  the  bladder  common  ? 

What  is  meant  by  cystitis  dolorosa  ? 

What  is  meant  by  parenchymatous  cystitis? 

Whenever  the  posterior  urethra  is  involved  and  when  the  inflammation 
has  passed  to  the  bladder  by  extension,  what  part  is  mostly  involved? 

What  is  meant  by  a  urethrocystitis? 

Of  what  value  is  the  Thompson  two-glass  method  in  cases  of  cystitis? 

What  is  the  treatment  of  acute  cystitis?  Give  the  internal  treatment  in 
detail.  What  is  the  local  therapy — in  acute  cases?  in  chronic  cases?  in 
cases  where  there  are  no  complications? 


QUESTIONS.  209 

How  is  the  differential  diagnosis  made  between  acute  anterior  and  acute 
posterior  urethritis  aud  a  urethrocystitis? 

What  is  meant  b.y  hypertrophy  of  the  bladder  ?  In  concentric  hypertrophy, 
is  there  a  large  quantity  of  urine  retained  ? 

What  varieties  of  tumor  of  the  bladder  are  met  with  ? 

Are  they  often  primary  in  origin? 

What  are  the  common  benign  tumors  ?    What  characteristics  do  they  show  ? 

What  are  the  malignant  tumors  ?     Which  is  the  most  common  ? 

What  are  the  subjective  symptoms? 

What  are  the  objective  symptoms  of  tumor  of  the  bladder? 

Of  what  value  is  cystoscopy  in  these  cases  ? 

What  is  their  treatment  ? 

Can  they  be  treated  intravesically  ?  If  so,  how,  and  what  kind  of  treat- 
ment is  thus  adopted  ? 

How  are  the  malignant  tumors  treated  ? 

If  complications  are  present,  how  are  they  treated? 

Are  foreign  bodies  ever  found  in  the  bladder  ?  How  do  they  reach  the 
bladder?     How  are  they  diagnosed  ? 

How  can  they  be  removed  if  not  too  large  ?  If  of  large  size,  how  are  they 
removed  ? 

What  is  meant  by  stone  in  the  bladder? 

How  are  they  found?    Describe  their  appearance. 

What  are  the  more  common  chemical  constituents  of  these  stones? 

Give,  succinctly,  the  chemical  analyses  of  the  different  stones. 

What  symptoms  do  they  present? 

If  complicated  with  ulcer  or  cystitis,  do  the  symptoms  differ  ?  How  and 
why? 

How  is  the  diagnosis  established? 

What  is  the  prognosis  ? 

What  is  their  treatment? 

What  is  meant  by  litholysis  ? 

What  is  litholapaxy?    Describe  in  detail  this  operation. 

Are  there  any  complications  which  do  not  permit  of  its  being  carried  out? 

What  complications  can  follow  litholapaxy? 

What  is  the  after-treatment? 

What  do  you  know  about  the  perineal  operations  ? 

Describe  the  perineal  operations. 

In  what  cases  is  this  operation  advisable  ?  When  would  you  remove  a 
stone  by  a  suprapubic  incision  ? 

Describe  the  suprapubic  operation  when  with  and  without  complications. 

What  are  the  advantages  and  disadvantages  of  this  method? 

What  is  the  after-treatment  ? 

What  is  meant  by  neuroses  of  the  bladder? 

How  is  such  a  diagnosis  made  ? 

What  is  the  treatment? 

What  is  meant  by  a  spasm  of  the  bladder?    Describe  in  detail. 

What  is  the  treatment  for  this  condition? 

What  is  meant  by  atony  of  the  bladder?    What  are  the  causes? 

How  is  the  diagnosis  made  ? 

What  is  the  treatment  ? 

What  is  meant  by  paralysis  of  the  bladder  ? 

What  are  the  causes  ? 

What  is  the  treatment? 

What  may  arise  if  the  bladder  is  emptied  too  q^alckly  1 

14— Y.  D. 


210  SEXUAL  DISORDERS  OF  THE  MALE. 

Does  incontinence  ever  occur  in  these  cases  ?    When  ? 

What  is  enuresis? 

What  may  the  causes  be  ? 

What  is  enuresis  nocturna  ?    Diurna? 

What  is  the  treatment  ? 

SEXUAL  DISORDERS  OF  THE  MALE. 

For  the  purpose  of  convenience  all  disorders  classed  under 
this  heading  may  be  divided  into  three  groups  :  (1)  Patholog- 
ical losses  of  semen ;  (2)  impotence ;  (3)  sterility.  It  is 
almost  unnecessary  to  state  that  these  may  intermingle  with 
one  another. 

Pathological  Losses  of  Semen. 

It  is  best  to  state  that  every  pollution  is  not  due  to  disease, 
but  that  there  are  physiological  pollutions — i.  e.,  losses  of  semen 
at  times  of  erections  during  sleep,  occurring  from  time  to 
time  after  the  age  of  puberty.  These  jDoUutiones  nocturncdes 
(nocturnal  pollutions)  are  usually  accompanied  by  erotic 
dreams. 

Pollutions  become  pathological  only  on  account  of  their 
frequency  and  the  ill  effects  they  exert  upon  the  individual. 
As  regards  their  frequency,  no  sharp  distinction  between 
physiological  and  pathological  pollutions  can  be  made.  The 
mode  of  living,  the  temperament  of  the  individual,  and  his 
constitution  all  take  part  in  deciding  the  question.  As  regards 
their  number  within  a  definite  period  of  time  and  the  fre- 
quency with  which  they  may  occur  and  still  be  physiological, 
no  definite  statement  can  be  made.  One  pollution  in  ten  or 
fifteen  days  in  a  healthy  individual  who  abstains  from  inter- 
course may  be  regarded  as  a  normal  condition.  Pollutions 
may  occur  oftener,  and  so  long  as  there  is  no  mental  depres- 
sion or  feeling  either  of  mental  or  of  physical  exhaustion, 
or  of  both,  it  must  be  regarded  within  the  physiological 
limits.  As  soon  as  an  individual  is  thus  affected  or  if,  in 
addition,  pollutions  occur  on  account  of  mechanical  stimula- 
tion, as  when  riding  horseback  or  on  touching  the  genitals 
during  the  day  {jpollutiones  diurnales),  and  especially  if  erec- 
tions are  absent,  the  condition  is  pathological. 


PATHOLOGICAL  LOSSES  OF  SEMEN.  211 

Spermatorrhoea — a  more  or  less  continuous,  spontaneous 
flow  of  semen — is  a  rare  condition,  and  is  entirely  distinct 
from  any  relation  to  pollutions.  A  loss  of  semen  which  is 
quite  common  at  the  time  of  defecation  is  referred  to  as  defe- 
cation spermatori'licea ;  at  the  time  of  urination,  micturition 
spermatorrhcea.  At  these  times  a  distinct  spasm  resembling 
contraction  in  the  perineum  is  usually  felt.  If  there  is  an 
admixture  of  sperma  in  the  urine  without  any  noticeable 
symptom,  it  is  termed  spei^maturia.  There  may  be  pollutions, 
spermatorrhoea,  and  spermaturia  p7'esent  in  one  and  the  same 
case.  There  is,  however,  not  necessarily  any  direct  connection 
one  with  the  other. 

Pollutions  may  be  regarded  as  motor  neuroses — spasms  of 
the  seminal  vesicles ;  while  spermatorrhoea  is  a  paresis  of  the 
ejaculatory  ducts. 

Etiologic  Factors, — There  are  diflPerent  elements  causing 
these  conditions  :  constitutional  diseases,  during  convalescence 
from  an  acute  febrile  disease,  tuberculosis ;  organic  diseases 
of  the  central  nervous  system,  especially  diseases  of  the  cord. 
Pathological  conditions  of  the  genito-urinary  tract  are,  how- 
ever, the  most  important  causes.  Following  or  during  the 
course  of  a  posterior  urethral  infection,  whether  of  a  gonor- 
rhoea! or  non-gonorrhoeal  character,  is  by  far  the  most  common 
local  cause.  It  must  not  be  forgotten  that  any  condition, 
especially  if  involving  the  posterior  urethra  with  its  adnexa, 
may  be  the  cause. 

The  defecation  and  micturition  spermatorrhoeas  are  very 
common.  Besides  this,  occasionally  after  instrumental  exam- 
ination there  is  loss  of  semen,  and  it  has  been  termed  artificial 
spermatorrhoea.  In  connection  with  all  these  different  forms 
and  when  a  localized  posterior  disorder  exists,  a  neurasthenic 
condition  often  accompanies  them,  and  is  referred  to  as  sexual 
neurasthenia.  Again  a  neuropathic  tendency  is  an  important 
factor  in  the  cause  of  these  affections.  In  these  cases  there 
is  usually  congenital  or  acquired  ansemia,  general  weakness, 
and  an  "irritable  weakness"  of  the  nervous  system.  In 
order  to  produce  this,  psychical  conditions,  such  as  fright, 
excesses  in  venery,  onanism,  and  coitus   interruptus,  take  a 


212  SEXUAL  DISORDERS  OF  THE  MALE. 

leading  part.  The  last  condition,  also  referred  to  as  coitus 
reservatus,  is  the  interruption  of  the  act  of  intercourse — the 
withdrawal  of  the  penis  just  previous  to  the  orgasm. 

The  diagnosis  should  always  be  made  with  the  aid  of  the 
microscope,  to  differentiate  from  other  discharges,  such  as 
urethrorrhoea  and  prostatorrhoea. 

The  prognosis  must  naturally  vary  as  to  the  cause.  In  all 
cases  it  may  be  stated  that  the  longer  the  duration,  the  worse 
the  outlook.  The  prognosis  varies  also  as  to  whether  or  not 
the  different  types  are  all  present. 

Treatment. — This  naturally  falls  into  the  prophylactic  and 
curative.  The  former  must,  of  course,  include  the  teaching 
of  the  prophylaxis  of  venereal  diseases,  the  avoidance  of  sex- 
ual excesses,  onanism,  or  any  practice  that  may  lead  to  this 
condition.  It  is  almost  needless  to  state  that  whenever  dis- 
tinct organic  conditions  are  present,  they  must  be  attended  to, 
no  matter  whether  constitutional  or  not.  If  local,  such  as  a 
posterior  urethritis,  this  must  receive  close  attention. 

Local  Treatment. — This  has  already  received  attention 
under  the  different  headings.  Whenever  these  conditions, 
general  or  local,  have  been  thoroughly  attended  to,  a  correct 
application  of  hydrotherapeutics  is  to  be  advocated.  At  the 
same  time  the  sexual  neurasthenia  which  accompanies  these 
conditions  must  never  be  neglected.  It  is  in  these  cases  that 
suggestive  therapeutics  may  be  of  great  value.  Following 
the  local  treatment  for  the  pathological  conditions,  a  treat- 
ment with  the  Winternitz  psychrophore,  an  instrument  re- 
sembling a  catheter,  but  Avithout  an  eye,  divided  into  two 
parts,  through  which  cold  water  may  be  passed,  is  to  be 
inserted  into  the  urethra  and  used  for  at  least  fifteen  minutes 
from  three  to  five  times  a  day.  Electrical  treatment  with  the 
galvanic  or  faradic  current  is  useful.  Here  a  urethral  elec- 
trode is  introduced,  and  in  the  case  of  the  galvanic  current, 
it  should  be  the  inactive  pole,  and  the  other  electrode  placed 
on  any  other  part  of  the  body,  as  the  pubes  or  perineum. 
Faradic  electricity  is  similarly  passed  for  a  few  minutes  at 
least  once  a  day.  These  various  treatments,  as  a  rule,  have 
not  been  very  successful.     Internal  treatment  is  in  most  cases 


IMPOTENCY.  213 

necessary  :  always  treat  the  direct  cause  ;  if  iron  or  arsenic  is 
necessary,  it  should  not  be  omitted.  The  more  common  cases 
require  the  following  medication : 

i^     Acidi  camphorici,  10.0  grammes. 

Div.  in  caps.  No.  xx. 

Sig. — Two  or  three  capsules  at  night. 

I^     Caraphorse  monobromatse, 

Lupulini,  aa  5.0  grammes. 

Div.  in  caps.  No.  xv. 
Sig. — Two  or  three  capsules  each  night. 

I^     Ext.  belladonnse,  0.15  gramme; 

Antipyrini,  5.00  grammes. 
Div.  in  caps.  No.  xv. 

Sig. — One  or  two  capsules  late  in  the  evening. 

Impotency. 

By  this  term  is  meant  the  inability  of  the  male  to  have 
intercourse  in  the  normal  manner — potentia  coeundi.  Cor- 
rectly speaking,  it  refers  to  abnormalities  of  erection,  and  the 
condition  of  potentia  generandi  is  not  necessarily  to  be  in- 
cluded, as  this  has  reference  only  to  the  power  of  fertilization. 
Sometimes  congenital  malformations  or  diseases  causing  de- 
formities, as  hydrocele,  rupture,  etc.,  again,  where  destruc- 
tion of  the  penis  has  occurred,  are  necessarily  the  causes  of 
organic  impotency.  Drugs,  such  as  morphine,  camphor,  lupu- 
lin,  and,  in  cases  of  intoxication  with  alcohol  or  lead,  also 
marasmus,  may  produce  a  "nervous'^  impotency.  Psychical 
impotency  is  the  condition  noticed  in  newly  married  people. 
In  these  cases  fright  or  mental  impressions  tend  to  prevent  the 
occurrence  of  erections.  Relative  impotency  is  a  term  applied 
whenever  it  is  impossible  to  have  intercourse  with  a  normally 
built  woman  when  under  sexual  excitement  no  erection  occurs. 
Neurasthenic  impotency  is  referable  to  the  cases  suffering 
from  neurasthenia.     In  these  cases  there  may  be  pollutions, 


214  SEXUAL  niSOBDEBS   OF  THE  MALE. 

and  both  conditions  must  naturally  be  considered  together. 
In  this  particular  class  of  cases,  once  in  a  while  the  individ- 
uals are  perfectly  capable  of  having  erections  and  intercourse, 
and  again  these  are  lost ;  this  is  termed  temporary  impotency. 
In  those  individuals  in  whom  there  are  complete  loss  of 
sexual  excitability  and  absence  of  erections  the  condition  is 
regarded  as  a  paralytic  impotency. 

The  prognosis  depends  naturally  on  the  variety  of  the 
affection ;  therefore  the  correct  diagnosis  must  first  be  made. 
If  dependent  on  structural  conditions,  the  prognosis  is  good 
if  they  can  be  corrected.  As  a  whole,  however,  it  is  best  to 
understand  that  the  results  are  very  unfavorable. 

The  treatment  varies.  If  there  are  organic  changes,  oper- 
ative interference  is  indicated.  AflFection  of  the  constitution 
and  the  central  nervous  system  must  each  receive  appropriate 
treatment.  Nephritis,  diabetes,  and  locomotor  ataxia  are 
the  most  common  diseases  in  which  this  symptom  is  present, 
and,  in  fact,  occasionally  it  is  the  first  symptom.  Psychical 
impotency  requires  psychical  treatment.  This  is  paramount 
in  all  cases  of  this  class.  Assurance  of  success  must,  of 
course,  naturally  be  given  very  guardedly.  No  patient  should 
attempt  the  sexual  act  too  often,  especially  if  failures  are  the 
rule.  Weeks  and  even  months  should  intervene.  Neuras- 
thenic impotency  must  be  treated  from  the  standpoint  of 
the  etiologic  factor.  If  ansemia  is  present,  this  must  be 
treated.  Besides  this,  hydropathic,  dietetic,  and  hygienic 
measures  must  be  ordered.  In  all  the  cases  of  neuroses, 
and  where  not  accompanied  by  any  organic  or  inflammatory 
change,  local  treatment  is  best  omitted.  It  is  just  in  this 
type  that  instrumental  treatment  and  applications  with  irri- 
tating chemicals  often  cause  change  for  the  worse.  How- 
ever, in  all  the  types  of  nervous  impotency — neurasthenic 
and  paralytic — hydrotherapy  is  of  value.  Probably  seashore 
bathing  is  desirable  ;  however,  a  large  number  of  patients 
cannot  afford  this  luxury,  hence  substitutes  for  this,  in  the 
way  of  cool  baths,  douches,  etc.,  are  desirable.  In  addition 
to  this  electrical  treatment  is  certainly  of  great  value  and 
must  never  be  omitted.     It  must  be  given  carefully, — either 


STERILITY.  215 

tlie  faradic  or  the  galvanic  current, — and  the  rule  is,  the 
more  sensitive  or  the  more  painful  the  application,  the  weaker 
is  the  current,  and  the  more  carefully  applied,  the  better  are 
the  results.  Of  late  various  mechanical  devices  which  give 
support  to  the  organ  have  been  used,  but  are  of  doubtful 
value.  Therapeutical  treatment  practically  confines  itself  to 
organotherapy — i.  e.,  preparations  made  from  the  testes,  and 
given  either  internally  or  subcutaneously.  Besides  this, 
strychnine,  phosphorus,  and  cocaine,  in  physiological  doses, 
are  useful. 

Sterility. 

In  this  class  of  cases  are  included,  in  the  male,  only  those 
in  which  the  semen  ejaculated  has  not  the  power  of  fertiliza- 
tion. There  may  be  absence  of  erections — irnpotenfia  coeundi — 
and  of  the  power  of  fertilizing  an  ovum — impotentia  gener- 
andi.  Either  one  or  the  other  of  these  conditions  may  be 
present  or  absent. 

There  may  be  an  absence  of  ejaculate.  In  some  cases  the 
ejaculate,  which  may  or  may  not  contain  spermatozoa,  regur- 
gitates, and  this  is  referred  to  as  cispermatismus.  It  may  be 
due  to  stricture  of  the  urethra,  occlusion  of  the  ejaculatory 
ducts,  or  may  even  be  psychical.  If  the  ejaculate  is  free 
from  spermatozoa,  the  condition  is  referred  to  as  azoospermia. 
In  these  cases  there  may  be  a  disease  of  the  testes,  as 
atrophy,  or  it  may  be  due  to  occlusion  of  the  vasse  deferentise, 
or  even  in  cachectic  diseases.  Whenever  the  number  of 
spermatozoa  are  compared  with  the  normal  number,  and  they 
are  found  to  be  decreased,  this  is  spoken  of  as  oligospermia; 
if  the  spermatozoa  have  but  slight  motility,  as  a,sthenozo- 
ospermia;  and  if  non-motile,  as  necrospermia. 

Diagnosis. — Necessarily  a  thorough  physical  examination 
is  indicated,  but  the  examination  of  an  ejaculate  is  neverthe- 
less obligatory  in  order  to  differentiate  the  one  from  the 
other.  In  azoospermia  the  microscopical  examination  reveals 
absence  of  spermatozoa  and  secretions  only  from  the  prostate, 
either  mixed  or  unmixed  with  secretion  from  the  seminal 
vesicles.     In  cases   of  oligospermia,    asthenozoospermia,    or 


216  SEXUAL  DISORDERS  OF  THE  MALE. 

necrospermia,  spermatozoa  are  present  in  the  first  in  dimin- 
ished number  ;  in  asthenozoosperraia  there  are  usually  changes 
in  form,  due  to  rapid  development  and  low  vitality ;  while 
in  the  latter  the  spermatozoa  are  non-motile. 

The  prognosis  varies.  In  aspermatismus  it  is  good  if  the 
organic  changes  can  be  arrested.  In  the  other  cases  the  prog- 
nosis is  always  doubtful. 

The  treatment  must  also  vary  with  the  cause.  If  these  are 
strictures,  then  these  should  receive  appropriate  treatment. 
If  old  chronic  epididymitis  is  the  cause,  resolvents  and  mas- 
sage of  the  parts  are  indicated.  If  due  to  cachectic  diseases, 
syphilis,  or  tuberculosis,  then  rational  medication  is  demanded. 
Finally,  if  chronic  posterior  urethral  diseases  are  present,  and 
the  prostate  or  seminal  vesicles  are  affected,  massage  of  these 
and  instillation  to  the  parts  constitute  the  treatment.  In 
certain  cases  dietetic  and  electrical  treatment  and  the  like 
should  be  instituted. 

Masturbation. 

As  an  etiologic  factor  onanism,  or  the  irritation  of  the 
external  genitalia  by  an  individual  himself  (male  cases  under 
consideration),  usually  producing  erections  and  causing 
orgasms,  also  called  masturbation,  is  of  such  significance  as  to 
need  a  few  words  of  attention.  This  practice  has  been  com- 
mon to  all  races  and  ages.  It  is  practised  by  the  young  as 
well  as  by  the  old.  It  is  of  most  importance  when  practised 
during  adolescence.  Whenever  the  habit  has  been  persistent 
and  frequent,  it  apparently  influences  the  constitution  of  the 
individual.  The  cause  cannot  always  be  elicited,  but  in  some 
cases  abnormalities  of  the  external  genitalia,  phimosis,  etc., 
stone  in  the  bladder,  or  even  inflammatory  disturbances, 
especially  involving  the  posterior  urethra,  may  be  found 
present.  It  leads  up  to  a  characteristic  condition  of  affairs 
practically  similar  to  sexual  neurasthenia,  yet  as  the  most 
prominent  complex  of  symptoms  may  be  mentioned  loss  of 
energy  for  work,  inability  to  concentrate  the  mind,  and  path- 
ological losses  of  semen. 


MASTURBATION.  217 

Treatment. — This  varies.  If  the  cause  is  ascertainable, 
this  should  be  rectified ;  if  not,  tonics,  hydrotherapy,  electric- 
ity, and  suggestion  therapy  are  the  most  important.  As  sexual 
neurasthenia  may  accompany  or  follow  masturbation,  impo- 
tenoy,  losses  of  semen,  and  sterility,  it  will  be  best  to  discuss 
briefly  this  most  important  topic.  It  is  now  a  distinct  neuro- 
pathic affection,  yet  cannot  easily  be  confined  to  narrow  limits, 
but  as  the  etiologic  factor,  some  genital  disturbance  seems  to 
be  fundamental,  usually  persisting  and  accompanied  by  various 
symptoms  referable  to  the  external  or  internal  genitalia,  such 
as  hypersesthesia,  anaesthesia,  and  indefinite  pain  involving 
these  parts.  Besides,  there  are  symptoms  arising  in  the  cere- 
brum, as  involvement  of  all  the  special  senses,  and  indefinite 
symptoms  from  any  organ  may  arise  and  persist.  Here, 
again,  the  treatment  varies  and  the  cause  must  be  looked  for 
and,  naturally,  be  treated.  In  addition  the  treatment  already 
outlined  under  the  various  headings  must  be  considered. 

Occasionally  nothing  but  sexual  intercourse  will  effect  a 
cure. 

QUESTIONS  ON  THE  SEXUAL  DISOEDEES  OF  THE  MALE. 

What  groups  are  there  of  these  disorders? 

What  is  meant  by  a  pathological  loss  of  semen? 

Are  there  physiological  losses  of  semen  ? 

What  is  nocturnal  pollution  ? 

When  do  pollutions  become  pathological? 

How  do  they  affect  the  individual  ? 

Do  pollutions  ever  occur  during  the  day  ?  If  so,  of  what  importance  are 
they? 

What  is  spermatorrhoea,  defecation,  micturition,  and  artificial  spermator- 
rhoea? 

What  is  meant  by  spermaturia  ? 

What  are  these  conditions  due  to? 

What  are  the  etiological  factors? 

How  is  the  diagnosis  made  ? 

What  is  the  treatment?    Describe  in  detail. 

What  is  meant  by  impotency  ? 

What  is  "organic,"  "nervous,"  "psychical,"  "relative,"  "neurasthenic," 
"temporary,"  impotency? 

What  is  the  prognosis  in  these  different  classes? 

What  is  the  treatment  in  these  different  classes? 

What  is  meant  by  sterility  ? 

What  is  impotentia  coeundi? 

What  is  impotentia  generandi  ? 

What  is  aspermatismus? 


218  THE   URETERS  AND  KIDNEYS. 

What  is  azoospermia? 

What  is  oligospermia  ? 

What  is  asthenozoospermia  ? 

What  is  necrospermia  ? 

How  is  the  diagnosis  of  these  conditions  made  ? 

What  is  their  prognosis? 

What  is  their  treatment? 

What  is  meant  by  masturbation  ? 

W^hat  is  often  the  cause? 

Wliat  does  masturbation  lead  to? 

What  is  the  treatment  of  masturbation  ? 

What  is  meant  by  sexual  neurasthenia  ? 

CONGENITAL  ANOMALIES,  INJURIES,  AND 

DISEASES   OF  THE  URETERS,  PELVES 

OF  KIDNEYS,  AND  KIDNEYS. 

CONGENITAL  ANOMALIES  OF  THE  URETERS. 

Anomalies  of  these  organs  occur  most  often  at  the  upper  or 
kidney-end,  but  the  bladder-end  is  also  occasionally  involved. 

Double  ureters  have  been  frequently  observed.  In  most 
cases  the  ureteral  opening  is  into  the  usual  place  in  the  blad- 
der, but  once  in  a  while  they  have  been  noticed  to  have 
abnormal  locations  in  the  bladder,  and  may  even  end  in  the 
urethra.  Urethroscopic,  cystoscopic,  and  skiagraphic  exam- 
inations will  often  verify  a  diagnosis.  The  treatment  is  nec- 
essarily an  operative  one  if  it  is  deemed  advisable. 

INJURIES  TO  THE  URETER. 

Symptoms  vary  with  the  exact  nature  of  the  injury : 
whether  or  not  complete  passing  of  urine  from  the  kidney 
has  occurred;  whether  only  a  crushing  injury  has  transpired, 
and  then,  in  the  course  of  some  days,  a  necrotic  condition 
and  perforation  arise,  allowing  a  collection  of  urine  in  the 
retroperitoneal  space.  If  the  injury  to  the  ureter  opens  up 
the  general  peritoneal  cavity,  the  urine  escapes  chiefly  into 
it,  and  then  in  a  short  time  the  symptoms  of  septic  perito- 
nitis arise.  Urine  in  the  peritoneal  cavity  is  diagnosed  by 
a  decrease  in  total  quantity  of  urine  voided  and  the  signs  of 
fluid  by  rectal  and  vaginal  examination.  In  women  aspira- 
tion helps. 


DISEASES  OF  THE   URETER.  219 

Diagnosis. — It  is  to  be  remembered  that  a  careful  palpation 
through  the  abdomen  is  necessary,  and  the  lower  end  can 
often  be  felt  through  the  vagina  and  also  through  the  rectum. 

From  the  foregoing  it  must  be  noted  that  the  quantity  of 
urine  passed  by  the  urethra  is  less  than  normal,  besides, 
whether  or  not  it  is  tinged  with  blood ;  the  gradual  or  rapid 
formation,  with  severe  symptoms,  of  a  fluctuating  tumor  in 
the  course  of  the  ureters,  or  especially  the  lumbar  regions, 
from  which,  by  aspiration,  a  hemorrhagic  urine  may  be 
gained.  Whenever  the  symptoms  are  progressive,  an  incision 
which  will  reach  the  ureter  extraperitoneally  should  be  made. 
If  the  symptoms  subside,  no  immediate  operative  interference 
is  necessary.  In  cases  of  complete  destruction  of  the  ureter 
it  may  even  be  necessary  to  remove  the  kidney.  If,  at  the 
time  of  operation  or  after  the  establishment  of  a  fistula,  injury 
to  the  ureter  has  occurred,  anastomosis,  by  one  of  the  many 
operations  proposed  for  these  conditions,  may  be  undertaken. 
In  all  vaginal  and  abdominal  operations  great  care  must  be 
taken  to  avoid  the  ureters.  Even  catheterization  and  allowing 
catheters  to  remain  in  situ  during  an  operation  have  been 
advocated,  in  order  to  furnish  fixed  landmarks  of  the  course 
of  these  organs  with  relation  to  the  deep  operative  field. 

DISEASES  OF  THE  URETER. 

Ureteritis,  an  inflammation  of  the  ureter,  may  occasionally 
arise  primarily,  but  is  most  often  an  extension  from  some 
inflammatory  process  either  descending  from  the  kidney  or 
ascending  from  the  bladder.  Ureteritis  cystica  is  a  distinct 
disease  and  may  exist  per  se.  It  consists  of  cystic  forma- 
tions covering  more  or  less  the  entire  mucous  membrane  sur- 
face of  the  ureters.  Other  benign  tumors,  such  as  the 
benign  polypi  of  the  bladder,  have  been  frequently  observed. 
Malignant  tumors,  however,  such  as  carcinomata,  are  almost 
always  secondary.  Stones  may  lodge  in  the  ureter,  either 
wholly  or  partially  obstructing  the  flow  of  the  urine,  or  may 
even  be  situated  in  a  sacculation  of  the  ureters.  Valves, 
strictures,  or  angulations,  as  well  as  all  the  preceding  con- 
ditions, may  give  rise  to  hydrone])hrosis. 


220  TBE   URETERS  AND  KIDNEYS. 

Diagnosis. — All  points  regarding  kidney  and  bladder  symp- 
toms must  be  excluded,  and  on  palpation  in  the  acutely  in- 
flamed area,  tenderness  is  present.  In  the  chronically  in- 
flamed, a  thickened  ureter  may  be  felt. 

Periureteritis,  probably  due  to  the  passage  of  stones  through 
the  ureter,  may  occur. 

The  treatment  in  all  except  acutely  inflammatory  cases 
must  necessarily  be  operative. 

Hydronephrosis. 

Causes. — This  is  a  dilatation  of  the  pelvis,  and,  in  the 
further  course  of  the  calyces  of  the  kidney,  and  due  to  a 
mechanical  obstrCiction  of  urinary  outflow :  in  other  words, 
due  to  retention  of  urine.  This  obstruction  is  situated  either 
low  down  in  the  ureter  or  high  up  where  the  ureter  is  attached 
to  the  pelvis  of  the  kidney.  It  may  be  congenital  or  acquired. 
The  obstruction,  when  low  down,  may  be  caused  by  impacted 
calculi,  by  distortion,  or  by  compression  of  the  ureter  by 
tumors  or  cicatricial  processes  following  inflammatory  con- 
ditions or  even  traumatism.  Or  the  obstruction  may  be  an 
artificial  one,  caused  by  the  ligation  of  the  ureter  during  an 
operation.  Obstructions  near  the  attachment  of  the  ureter 
are  caused  either  by  sacculation  of  the  pelvis  or  by  forma- 
tion of  obstructing  valves  or  folds.  Partial  obstruction  may 
be  due  to  tangential  insertion  of  the  ureter,  the  latter  being 
drawn  to  the  kidney  through  inflammatory  adhesions.  The 
condition  of  floating  kidney  may  bring  about  temporary 
obstruction  and  temporary  hydronephrosis  by  twisting  and 
bending  of  the  ureter.  This  may  recur,  followed,  perhaps, 
bv  periods  of  rest — the  so-called  intermittent  hydronephrosis. 
Through  the  pressure  which  becomes  increased  through  the 
additional  quantities  of  fluid,  aided  by  the  remittent  charac- 
ter, the  parenchyma  of  the  kidney  atrophies,  either  partially 
or  totally,  so  that  in  extreme  cases  only  a  sac  is  to  be  found, 
without  any  trace  of  secreting  tissue.  If  the  hydronephrosis 
is  a  moderate  one,  the  kidney  is  to  be  palpated  as  enlarged. 
Larger  accumulations  make  the  kidney  appear  as  a  fluctuating. 


HYDRONEPHROSIS.  221 

elastic  tumor  of  considerable  size.  Dislocations  of  these  tu- 
mors are  not  uncommon,  so  that  quite  often  they  have  been 
mistaken  for  abdominal  tumors — for  instance,  for  ovarian 
cysts. 

The  symptoms  may  vary  with  the  cause.  A  condition 
resembling  that  of  an  increasing  tumor  may  gradually  arise 
when  due  to  a  gradual  but  increasing  pressure  on  or  gradual 
narrowing  of  stricture  of  the  ureter,  which  may  be  of  an 
inflammatory  type ;  or  the  symptoms  may  arise  very  acutely 
when  due  to  an  obstruction  by  stone,  or  by  an  acute  bend  in 
the  ureter,  as  in  case  of  a  floating  kidney.  When  slowly 
forming,  the  symptoms  are  usually  loss  of  appetite,  constipa- 
tion, nausea,  feeling  of  fulness  in  the  abdomen,  and  later  a 
dull  ache,  and  even  pain  in  the  back,  which  may  radiate  to 
the  genitals.  All  these  symptoms  may  arise  suddenly  with 
the  greatest  acuteness.  There  may  be  marked  vomiting,  and 
a  rise  of  temperature  may  occur.  Whenever  the  sac  is  of 
large  dimension,  any  traumatism  may  cause  it  to  burst.  If 
of  long  standing,  the  entire  kidney  parenchyma  may  have 
become  destroyed.  It  may  become  infected  at  any  time,  and 
should  this  occur,  the  condition  becomes  more  grave. 

If  the  obstruction  is  only  a  partial  one  or  can  be  removed 
by  replacing  the  kidney, — as  in  cases  of  hydronephrotic 
floating  kidneys, — the  tumor  disappears  and  a  large  quan- 
tity of  urine  is  passed.  A  hydronephrosis  may  become  in- 
fected and  suppurate  in  consequence,  being  then  termed  a 
pyonephrosis,  and  presenting  signs  of  acute  inflammation, 
tenderness,  and  fever,  and  the  discharge  from  the  sac,  so  that 
the  urine  contains  pus  and  blood. 

.  If  a  hydronephrotic  tumor  becomes  of  very  large  size, 
symptoms  of  compression  in  the  abdominal  cavity  may  appear. 

Treatment. — In  cases  of  floating  kidney  the  therapy  con- 
sists in  anchoring  the  kidney  by  nephropexy.  If  the  seat  of 
the  existing  ureteral  obstruction  is  diagnosed,  it  is  necessary 
to  cut  down  to  this  place  and  eliminate  the  obstructing  factor 
(ureterotomy  for  impacted  calculus).  If  malformations  in 
the  ureteral  attachments  are  suspected,  the  pelvis  of  the 
kidney  is  split  open  and  the  necessary  plastic  operation  is 


222  THE   URETERS  AND  KIDNEYS. 

performed.  In  very  rare  cases  total  or  partial  extirpation  of 
the  hydronephrotic  sac  is  indicated.  If  only  a  small  amount 
of  secreting  tissue  is  left,  complete  restoration  of  the  renal 
function  is  always  to  be  hoped  for  if  favorable  conditions  for 
the  outflow  are  provided  and  the  hydronephrotic  pressure 
relieved. 

Suppuration  of  the  hydronephrosis  calls  for  evacuation 
through  a  lumbar  incision.  If  a  fistula  remains  after  any  of 
the  operations  and  it  cannot  be  relieved,  nephrectomy  may 
become  necessary.  There  may  be  exceptions,  but  most 
operations  are  best  done  by  the  retroperitoneal  route.  So- 
called  conservative  methods  have  also  been  used.  Aspiration, 
repeatedly  carried  out  on  one  and  the  same  patient,  has  been 
followed  by  good  results.  It  is,  however,  not  to  be  advised, 
but  may  be  considered  as  a  palliative  method.  Catheteriza- 
tion of  the  ureter  may  also  afford  relief,  but  can  scarcely  be 
expected  to  give  permanent  relief,  except  if  a  distinct  stricture 
were  the  cause.  If  an  organic  stricture  of  the  ureter  is  sus- 
pected, catheterization  had  best  be  omitted  on  account  of  the 
manifest  dangers  of  puncture. 

Pyelitis. 

Causes. — Pyelitis  is  the  suppurative  inflammation  of  the 
renal  pelvis  and  calyces.  The  condition  may  either  be  an 
acute  one  or  is  chronic,  with  occasional  exacerbations.  It  is 
produced  either  by  ascending  infection  through  the  bladder 
or  by  local  conditions ;  at  the  same  time  kidney  abscesses  or 
the  so-called  surgical  kidney  may  arise.  Chronic  retention 
of  urine  in  the  pelvis  or  the  presence  of  calculi  may  lead  to 
circulatory  disturbances  and  secondary  infection.  The  bacillus 
tuberculosis  may  also  produce  pyelitis.  Some  authors  claim 
that  certain  drugs  may,  by  their  chemical  action,  produce 
suppurative  inflammation  of  the  kidney. 

Symptoms. — These  are  variable  clinically.  In  acute  in- 
fectious diseases,  where  a  concomitant  kidney  afl'ection  occurs, 
there  are  irregular  fever,  nausea,  vomiting,  colicky  pains, 
pains  in  the  back,  radiating,  with  tenderness  over  the  affected 
area. 


PYELITIS.  223 

The  symptoms  of  pyelitis  are  deep-seated  pains  in  the 
small  of  the  back  and  in  the  region  of  the  kidney.  The 
pain  quite  often  radiates  into  the  hypogastric  regions.  The 
fever  is  usually  of  a  remitting  character.  Acute  attacks  or 
exacerbations  are  marked  by  chills.  The  urine  shows  pus- 
cells,  red  blood-corpuscles,  and  a  great  many  epithelial  cells. 
The  urine  is  turbid,  because  pus  is  thoroughly  mixed  with 
it ;  it  is  usually  of  a  light-brown  color,  and  the  quantity  is 
greater  than  normal.  In  order  to  decide  whether  the  pus 
comes  from  the  bladder  or  from  the  kidney,  and  from  which 
or  from  both  kidneys,  cystoscopy  and  ureteral  catheterization 
are  the  most  certain  methods.  By  observing  the  ureteral 
opening  through  the  cystoscope,  pus  may  be  seen  exuding, 
while  if  no  cystitis  is  concomitant,  the  inspection  of  the 
bladder-wall  will  reveal  a  normal  condition.  In  doubtful 
cases  ureteral  catheterization  will  show  which  kidney  is  dis- 
eased. If  the  pyelitis  leads  to  considerable  accumulation  of 
pus,  on  palpation  the  kidney  may  be  felt  as  a  large  and  very 
tender  tumor.  The  urinary  examination  must  be  carried  out 
carefully  in  these  cases.  The  efficiency  of  the  kidney  is 
established  with  the  methods  already  described  elsewhere. 
The  amount  of  pus  and  the  quantity  of  albumin  should 
be  accounted  for. 

If  the  kidney  is  not  opened  surgically,  pyelitis  may  lead 
to  peri  nephritic  abscess,  which  may  perforate  to  the  surface, 
thus  establishing  a  renal  fistula.  Through  such  fistula  calculi 
may  occasionally  be  voided.  In  all  cases  in  which  pyelitis  is 
of  long  standing,  or  where  the  acute  symptoms  are  very 
urgent,  nephrotomy  is  indicated.  After  this  drainage  must 
be  continued  until  all  signs  of  inflammation  have  disappeared. 
If  ureteral  obstruction  is  present,  this  should  be  attended  to 
at  the  time  of  the  nephrotomy.  If  abscesses  of  the  kidney 
are  very  diffuse  and  the  condition  complicates  pyelitis, 
nephrectomy  must  be  undertaken.  Some  cases  of  pyelitis 
may  be  benefited  by  general  treatment  and  by  the  drinking 
of  certain  mineral  waters.  In  connection  with  the  treatment 
regular  catheterization  and  irrigation  of  the  pelvis  with  anti- 
septic fluids  might  be  of  service  and  undertaken  in  certain  cases. 


224   CONGENITAL  MALFORMATIONS  OF  THE  KIDNEY. 

The  prognosis  is  always  serious.  If  pyelitis  is  bilateral,  it 
is  especially  gloomy. 

CONGENITAL  MALFORMATIONS  OF  THE  KIDNEY. 

Horseshoe  kidney  is  probably  always  due  to  the  union  of 
the  two  lower  poles,  thus  giving  the  shape  that  the  name  im- 
plies. It  is  comparatively  common.  Again,  a  single,  but 
usually  much  elongated,  kidney,  rounded  and  flat,  is  occasion- 
ally seen.  There  may  be  more  than  two  kidneys.  All  these 
deformities  necessarily  change  the  form,  position,  and  number 
of  kidneys,  and  practically  constitute  all  the  malformations 
that  may  occur.  However,  a  rudimentary  kidney  (a  hypo- 
plasia)  on  one  side,  or  a  complete  absence  of  one  kidney 
(^aplasia),  or  an  abnormally  large  kidney  (^hyperplasia),  are 
occasionally  met  with. 

INJURIES  TO  THE  KIDNEYS. 

Injuries  to  these  organs  are  comparatively  infrequent,  as 
the  kidneys  are  quite  thoroughly  protected,  yet  as  they  are  of 
importance,  it  will  be  best  to  mention  them.  They  may 
either  be — 

1.  Injuries  without  any  external  wound, 

2.  Injuries  with  open  wounds. 

The  mechanism  is  varied,  yet  direct  injuries  are  the  most 
common.  Of  the  first  variety  there  are  different  degrees,  and 
for  all  practical  purposes  these  may  be  classified  as  follows  : 

1.  Crushing  injuries  to  the  parenchyma,  to  the  perirenal 
tissue,  and  even  complete  separation  from  the  ureter  and  ves- 
sels. 

2.  Tears  of  the  capsule  with  the  parenchyma  of  the  kid- 
ney. 

3.  Contusions  of  the  fatty  capsule,  with  or  without  contu- 
sion of  the  kidney  parenchyma. 

In  the  second  class  of  cases  the  injuries  resulting  from  stabs 
or  gunshots  are  the  most  frequent.  They  are,  however,  often 
accompanied  by  injuries  to  other  organs.     If  this  is  not  the 


INJURIES  TO   THE  KIDNEYS.  225 

case,  then  whether  or  not  there  is  involvement  of  the  vessels 
or  the  peritoneum  is  to  be  considered. 

The  symptoms  must. naturally  vary  with  the  precise  nature 
of  the  injury.  With  or  without  traumatism  to  any  other  part 
of  the  body,  shock,  with  its  concomitant  symptoms,  may  occur 
at  once  and  continue  for  hours.  Pain  may  arise  at  once,  or 
first  make  its  appearance  later,  and  may  be  very  mild  in  char- 
acter or  most  excruciating.  It  may  become  progressively 
worse  if  the  ureter  has  become  severed  or  injured  or  obstructed, 
with  secondary  hydronephrosis,  and  if  hemorrhages  occur 
in  the  different  layers  of  the  tissue  about  the  kidney.  Crush- 
ing or  other  injuries  may  show  in  the  soft  parts,  or  even  the 
spine  and  ribs  may  indicate  externally  the  effects  of  the  same, 
and  then,  of  course,  take  part  in  the  symptoms.  Hcematuria, 
whenever  present, — and  it  is  present  in  the  larger  number  of 
cases, — is  of  the  greatest  import.  It  is  absent  in  those  cases 
which  do  not  affect  the  pelvis,  and  in  the  light  injuries,  or  in 
those  grave  injuries  where  there  is  complete  tearing  of  the 
ureter.  The  hemorrhage  may  be  steady,  so  that  the  flow 
down  the  ureter  into  the  bladder  is  constant  for  some  time,  or 
it  may  be  so  slight  that  microscopical  examination  of  the  sed- 
iment of  the  urine  may  be  made  in  order  to  detect  it.  Hem- 
orrhages which  occur  at  a  later  period, — days  to  weeks, — 
really  secondary  and  due  to  the  breaking  down  of  a  clot,  may 
occur.  Or,  again,  an  anuria  following  immediately  upon  the 
injuries  has  been  noted,  due  to  a  reflex  action.  But  wherever 
the  kidney  is  injured,  the  total  quantity  of  urine  is  usually 
diminished.  In  either  state  the  symptoms  of  uremia  may 
occur.  In  the  grave  cases,  catheterization  should  be  under- 
taken, as  the  patients  are  unable  to  urinate ;  this  urine  should 
then  be  examined  carefully.  Palpation  of  the  parts  should 
be  undertaken  cautiously,  and  sometimes  it  may  be  advisable 
to  palpate  under  anesthesia,  in  order  to  outline  any  swelling 
that  may  have  arisen  from  the  accident. 

The  prognosis  varies  with  the  severity  of  the  cases,  but  is 
naturally  grave. 

The  treatment  is  practically  symptomatic.  Shock,  hemor- 
rhage, and  the  progressive  formation  of  swelling  are  the 
io_v.  p. 


226  DISEASES  OF  THE  KIDNEY. 

important  factors  to  be  taken  into  consideration.  It  is  best 
in  all  other  cases  to  be  conservative  in  the  treatment.  Abso- 
lute rest  in  bed,  ice  pack  to  the  parts,  .hypodermic  injections 
of  morphine  to  conquer  the  pain,  and  diluents  for  the  urine 
are  needed.  Shock  may  mask  the  signs  of  an  internal  hem- 
orrhage, and  this  should  not  be  forgotten,  for  in  the  latter 
case  surgical  interference  is  imperative.  It  may  demand 
either  a  simple  nephrotomy  or  again  nephrectomy  may  be 
called  for,  depending  entirely  upon  the  character  of  the  in- 
jury. Complications,  as  uraemia,  secondary  infection,  etc., 
require  their  regular  treatment. 

THE  "ESSENTIAL"  HEMORRHAGES  FROM  THE  KIDNEYS. 

Causes. — Hemorrhages  from  the  kidneys  are  not  uncommon, 
occurring  in  cases  of  stone,  tumor,  traumatism,  following 
violent  exercise,  floating  kidney,  tuberculosis,  nephritis,  or 
any  inflammatory  condition,  hydronephrosis,  during  lactation, 
periodic  hemorrhages  due  to  oxalates,  and  any  condition 
causing  congestion  of  the  kidneys,  and,  finally,  in  individuals 
suiFering  from  hsemophilia.  Originally,  certain  hemorrhages 
whose  cause  could  not  be  differentiated,  even  if  belonging  to 
any  of  the  foregoing  classes  or  not  accountable  by  any  toxic 
or  infective  cause,  were  called  '' essential"  hemorrhages. 
This  term,  however,  is  used  only  when  a  hemorrhage  occurs 
from  the  kidney  in  which  no  pathological  condition  can  be 
found,  and  when  the  hemorrhage  can  be  accounted  for  only 
by  angioneurotic  disturbances,  the  vessels  dilating  to  such  an 
extent  and  bursting,  hence  causing  the  appearance  of  blood 
in  the  urine.  Since  this  use  of  the  term  has  been  made, 
"  essential "  hemorrhages  have  been  few  in  number,  and  it  is 
necessary  to  be  extremely  careful  in  making  the  diagnosis. 
In  some  of  the  cases  severe  pains — neuralgia — in  the  lumbar 
region  have  accompanied  the  hemorrhages,  and  these  may  be 
of  any  grade  of  severity. 

Diagnosis. — It  is  necessary  to  ascertain,  by  the  aid  of  the 
Harris  segregator  or  with  the  cystoscope,  best  with  catheteri- 
zation and  the  cystoscope,  whether  the   hemorrhage  occurs 


FLOATING  KIDNEY.  227 

from  one  or  from  both  kidneys,  and  then  to  exclude  all  the 
causes  mentioned. 

The  treatment,  if  the  hemorrhage  is  not  severe,  consists  of 
milk  diet,  rest  in  bed,  hydrastis,  and  ergot.  However,  if  the 
hemorrhage  continues  or  becomes  progressive,  nephrotomy  is 
to  be  advised.  If  the  diagnosis  has  been  correct,  tamponade 
is  to  be  employed.  Tuberculosis,  tumor,  stone,  and  other 
pathological  condition,  if  found  to  be  present,  may  demand  a 
different  procedure.  Nephrectomy  is  to  be  done  only  when- 
ever the  hemorrhage  can  be  arrested  in  no  other  manner. 

Kidney  Neuralgia. 

This  condition  has  become  less  common  as  accurate  diag- 
nosis has  become  more  common,  because  all  the  pathological 
conditions  enumerated  under  hemorrhages  have  also  been 
found  to  be  the  cause.  Hence  whenever  an  operative  inter- 
ference is  done  for  the  relief  of  this  symptom,  certain  patho- 
logical conditions  are  almost  always  found. 

Floating  Kidney. 

Causes. — It  is  due  to  anatomical  conditions.  The  fixation 
of  the  kidneys  in  their  position  is  a  relatively  unstable  one. 
In  no  case  is  the  kidney  absolutely  fixed,  for  there  occurs  a 
movement  imparted  by  respiration.  Whenever  the  kidney 
becomes  movable  beyond  this  limit,  it  has  been  termed  a 
"  floating  kidney." 

Diagnosis. — Such  a  kidney  may  be  found  in  different  posi- 
tions in  the  same  individual — oftentimes  in  the  pelvis.  Bi- 
manual palpation,  sometimes  under  anaesthesia,  establishes 
the  correctness  of  the  diagnosis. 

The  symptoms  are  most  varia})le  :  nausea,  vomiting,  con- 
stipation, icterus,  palpitation,  and,  in  women,  symptoms  refer- 
able to  the  internal  genitalia.  Occasionally  most  acute  symp- 
.toms  arise,  due  probably  to  some  obstruction  of  the  ureter. 

The  treatment  depends  upon  the  severity  of  the  case  as 
shown  by  the  symptoms.  Bandages,  corsets  with  the  aid  of 
certain  supports,  may  fix  the  kidney  in  such  a  way  as  to  free 


228  DISEASES  OF  THE  KIDNEY. 

the  patient  from  every  symptom  while  the  apparatus  is  worn. 
However,  operative  procedures  obviate  all  braces,  and  ideally 
are  correct,  but  many  recurrences  have  been  recorded.  These 
are  often  due  to  not  selecting  the  proper  operation.  If  this 
occur,  another  operation — one  particularly  adapted  to  the 
case — should  be  undertaken.  All  the  operations  aim  to 
reach  the  kidney  by  a  retroperitoneal  route,  yet  differ  in  the 
manner  of  "fixing"  the  kidney.  The  operation  is  called 
nephrorrhaphy  or  nephropexy. 

Syphilis  of  the  Kidney. 

Syphilis,  either  acquired  or  congenital,  manifests  itself  in 
three  ways:  (1)  Diffuse  nephntis ;  (2)  Amyloid  degeneration ; 
(3)   Gummata. 

In  cases  of  syphilitic  nephritis  there  are  fatty  degenerative 
changes,  occurring  usually  in  the  secondary  stage,  and  practi- 
cally giving  rise  to  the  symptoms  of  an  acute  Bright's  dis- 
ease. In  cases  of  amyloid  degeneration  the  liver  and  spleen 
are  also  thus  affected.  Gummata  may  occur  in  any  part  of 
the  kidney,  and  any  number  may  be  present.  All  forms 
may  be  associated  with  one  another. 

Symptoms. — The  clinical  signs  may  resemble  tumors  of 
the  kidney,  and  at  the  time  of  the  breaking  down  of  the 
gummata  tuberculosis  especially  must  be  excluded.  Only  in 
the  latter  cases,  practically,  is  surgical  interference  necessary 
— nephrotomy  and  removal  of  the  necrotic  tissue.  In  all 
the  varieties  antisyphilitic  treatment  is  absolutely  necessary. 

Tuberculosis  of  the  Kidney. 

The  probable  mode  of  infection  in  the  large  number  of 
cases  is  by  way  of  the  vascular  system  from  some  initial 
source.  It  may,  however,  ascend  from  the  bladder  or  by 
direct  extension  from  the  neighboring  organs. 

Tuberculosis  appears  either  as  miliary  tuberculosis  or  in- 
the  form  of  solitary  tubercles,  depending  upon  the  gravity 
of  the  infection.  The  former  manifests  itself  by  minute 
tuberculous  nodules  scattered  throughout  the  kidney  or  just 


TUBERCULOSIS  OF  THE  KIDNEY.  229 

under  the  capsule,  which  appear  as  gray  granulations  in  the 
tissue  between  the  tubules.  If  these  nodules  are  crowded 
together  and  break  down,  cheesy  degeneration  of  the  kidnej' 
takes  place.  The  kidneys  may  become  enormously  enlarged 
and  uneven  on  their  surface,  and  the  capsule  much  thick- 
ened. With  the  progress  of  the  cheesy  degeneration  large 
cavities  are  formed  which  fill  with  detritus  and  pus.  When- 
ever such  a  cavity  empties  itself  into  the  pelvis,  it  gives 
occasion  for  obstruction  of  the  ureter  and  for  retention.  The 
solitary  tubercles  are  found  as  rather  large  nodules  in  the 
pelvis  or  in  the  parenchyma,  microscopically  containing  giant- 
cells  surrounded  by  round-cell  infiltration.  Sometimes  calci- 
fication may  set  in,  and  the  kidney  may  retain  its  normal 
shape  and  size ;  or,  again,  a  fibrous  change  occurs  or  para- 
nephritic abscesses  may  form.  In  any  of  these  cases  tubercu- 
losis of  the  ureter  may  occur,  and  the  ureter  may  become 
enormously  thickened.  Tuberculosis  is  readily  transplanted 
from  the  ureter  to  the  bladder,  either  from  above  the  detritus 
and  urine  or  by  direct  extension  of  the  tuberculous  process. 

In  all  cases  of  tuberculosis  of  the  kidney  it  is  of  the  most 
vital  importance  to  determine  whether  or  not  both  kidneys 
are  affected.  From  the  pathological  outline  it  can  readily 
be  seen  that  there  can  be  no  uniformity  of  symptoms ;  hence 
the  possibility  of  its  presence  can  only  be  surmised.  The 
beginning  of  an  attack  may  be  entirely  free  from  any  symp- 
toms, and  if  calcification  sets  in,  no  symptoms  whatever  may 
arise. 

Symptoms. —  While  miliary  tubercles  do  not  necessarily  give 
rise  to  kidney  symptoms  in  the  early  stages  of  the  disease, 
the  first  symptom  may  be  pain  on  urination,  and  even  tenes- 
mus with  pain  at  the  end  of  urination,  and  the  passing  of  large 
quantities  of  urine.  Afterward,  pain  in  the  lumbar  region, 
with  tenderness  on  pressure,  appears.  The  urine  contains 
albumin,  pus,  and  detritus  in  which  tubercle  bacilli  and  casts 
may  be  found.  Vesical  irritation  then  usually  becomes  a 
prominent  symptom.  Again,  the  course  of  the  disease  may 
be  entirely  different.  The  symptoms  may  be  tumultuous 
in  their  onset,  the  pain  most  severe  and  sometimes  colicky. 


230  DISEASES  OF  THE  KIDNEY. 

The  bladder  symptoms  are  greatly  aggravated.  The  kidney 
may  rapidly  enlarge  and  be  palpated,  and  the  urine  show 
albumin,  casts,  detritus,  red  blood-corpuscles,  epithelial  cells, 
and,  in  order  to  make  an  absolute  diagnosis,  tubercle  bacilli 
must  be  found  in  the  sediment  of  the  urine. 

These  most  acute  symptoms  may,  however,  subside,  and  in 
both  instances  the  kidney  may  or  may  not  be  found  to  be 
enlarged  or  have  a  nodulated  surface,  and  the  seat  of  con- 
stant dull  or  even  acute  pains.  Dysuria,  tenesmus,  pain  on 
urination,  pyuria,  and  even  hsematuria  may  all  be  present  in 
a  variable  degree.  Exacerbations  in  such  a  course  are  not  at 
all  uncommon.  It  is  not  unusual  for  such  a  course  of  symp- 
toms to  extend  over  a  period  of  years. 

Diagnosis, — Tuberculin  injections  may  be  of  service.  In 
tuberculous  kidneys  usually  a  greater  number  of  tubercular 
germs  appear  in  the  urine,  with  more  detritus  and  even  blood, 
greater  tenderness  over  the  area  of  the  kidney  affected,  and  a 
general  rise  in  temperature.  This  is  -of  the  greatest  impor- 
tance in  differential  diagnosis.  Sooner  or  later  constitutional 
symptoms  are  present,  and  manifest  themselves  by  fever, 
malaise,  weakness,  and  cachexia. 

Surgical  Treatment. — It  is  important  to  know  whether 
the  disease  involves  one  or  both  kidneys,  and  the  severity 
with  which  each  may  be  affected.  This  may  be  done,  as 
already  described  in  another  chapter,  by  the  following  meth- 
ods :  cystoscopy  reveals  the  presence  or  absence  of  bladder 
diseases ;  methylene-blue  or  phloridzin  reveals  the  efficiency 
of  the  kidneys  ;  besides,  the  collection  of  the  urine  separately 
from  the  two  kidneys,  either  by  the  aid  of  catheterization  or 
of  the  cystoscope,  by  which  one  or  both  ureters  may  be 
catheterized,  or  of  the  Harris  segregator,  and  an  examination 
the  separate  specimens  microscopically,  bacteriologically,  and 
chemically  for  pathological  elements.  Cystoscopy  discloses 
the  "  efficiency  "  of  the  kidneys.  Urine  may  also  be  injected 
into  guinea-pigs  in  order  to  establish  the  presence  or  absence 
of  the  germs. 

Medicinal  Treatment. — In  all  cases  this  should  be  instituted, 
whether  or  not   surgical  interference  is  to  be    undertaken. 


RENAL  CALCULUS.  231 

The  large  majority  of  surgeons  favor  immediate  interference  ; 
however,  all  doubtful  cases  should  be  treated  hygienically 
and  medicinally  with  the  usual  antituberculous  remedies. 
In  all  cases  where  there  is  no  improvement  and  where  the 
urine  continues  to  be  acid  and  the  bacilli  to  be  present,  and 
Avhere  the  symptoms  increase  in  severity,  it  becomes  necessary 
to  operate.  If  the  symptoms  are  very  acute,  such  as  colicky 
pain,  hemorrhages,  and  severe  pain,  progressive  at  once, 
surgical  intervention  should  be  carried  out  at  once.  If  it  is 
proved  absolutely  that  there  is  a  second  kidney  and  that  there 
is  a  normal  elimination  of  solids,  hence  absence  of  patholog- 
ical conditions,  the  entire  diseased  kidney  should  be  extir- 
pated (nephrectomy),  or  if  but  one  pole  is  alfected,  a  resection 
is  to  be  done,  thus  removing  the  entire  diseased  parts.  For- 
merly, when  the  condition  of  the  other  kidney  was  not  known, 
a  simple  nephrotomy  was  performed.  If  both  kidneys  are 
affected,  certain  conditions,  as  pain,  hemorrhages,  etc.,  may 
also  demand  nephrotomy  ;  however,  a  resection  might  also 
remove  the  pathological  area ;  hence  this  may  be  indicated 
in  some  cases.  Nephrotomy  is  also  performed  as  a  prelim- 
inary step  to  a  nephrectomy.  Here  acute  symptoms  may  thus 
be  alleviated,  and  then  the  secondary  step  becomes  more  free 
from  danger.  If  the  ureter  is  involved,  it  must,  necessarily, 
be  removed  at  the  time  of  nephrectomy. 

Renal  Calculus. 

Causes. — Stones  in  the  kidney  may  originate  in  the  tubules, 
in  one  of  the  calyces,  in  the  pelvis,  or  in  any  part  of  the 
kidney.  They  may  be  dislodged  from  their  situation  and 
passed  on  into  the  bladder,  or  they  may  remain  in  their  orig- 
inal site  and  enlarge  through  additional  depositions  of  uri- 
nary solids.  The  form  and  size  of  the  stones  are  influenced 
to  some  extent  by  their  location.  Those  of  the  parenchyma 
are  usually  small — of  a  bean-like  appearance ;  if  in  the  pel- 
vis, they  may  take  the  form  of  the  part  they  fill.  The  most 
common  forms  of  renal  calculi  are  those  of  uric  acid  and 
oxalate  of  lime.     In  rare  instances  the  carbonate  and  phos- 


232  DISEASES  OF  THE  KIDNEY. 

phate  of  lime  and  ammonium-magnesium  phosphates  are 
found,  and  rarely  cystine  and  xanthine  stones  occur. 

Etiology. — The  etiology  of  renal  calculi  is  somewhat  ob- 
scure. It  may  be  that  in  some  cases  a  shred  of  pus,  a  coag- 
ulated blood  particle,  mycelia  of  some  kind,  or  some  necrotic 
tissue  debris  acts  as  a  nucleus  around  which  a  deposition  of  the 
constituents  of  the  urine  takes  place.  Recent  researches  serve 
to  support  the  theory  that  at  least  a  part  of  the  renal  stones 
are  formed  under  bacterial  influence.  Stone  is  more  com- 
mon in  some  countries  than  in  others.  Certainly,  age  and 
mode  of  living  seem  to  be  etiologic  factors  in  their  formation. 
They  are  much  more  common  in  the  male  sex. 

Stones  which  do  not  produce  any  inflammation  and  do  not 
obstruct  the  urinary  outflow  may  be  retained  for  a  long  time 
without  giving  rise  to  any  special  symptoms.  Stones  in  the 
tubules  quite  often  cause  symptoms  which  are  in  no  way 
related  to  the  size  of  the  stones,  and  are  sometimes  accounted 
for  by  the  increased  tension  upon  the  kidney  capsule.  Stones 
in  the  pelvis  may  give  rise  to  chronic  dilatation  of  the  pelvis 
and  eventually  to  suppuration.  Every  stone,  however,  must 
act  as  an  irritant  and  be  the  forerunner  of  chronic  inflamma- 
tory or  degenerative  changes  in  the  parenchyma  of  the  kidney. 
These,  of  course,  may  be  variable,  depending  to  some  extent 
upon  whether  or  not  the  urine  from  the  kidney  harboring  the 
stone  remains  sterile.  Infection  usually  sets  in,  and  pyelitis 
and  nephritis  follow.  This  infection  may  be  ascending  or 
may  be  hematogenous.  A  stone  may  occlude  the  ureter  and 
a  hydronephrosis  or  pyonephrosis  result.  It  can  be  stated 
almost  positively  that  any  long-continued  process  of  this  kind 
will  always  influence  the  other  kidney  in  some  degree. 

The  subjective  symptoms  of  kidney  stones,  if  there  are  any, 
are  variable,  depending  upon  whether  or  not  the  stone  is  fixed 
in  the  parenchyma,  whether  movable,  so  that  it  may  cause 
obstructive  symptoms  from  the  ureter,  and  whether  or  not 
infection  is  present ;  they  usually,  however,  consist  in  dull 
pain  in  the  renal  region,  often  increased  by  exercise.  If  the 
stone  is  not  movable  and  if  no  infection  is  present,  pain  may 
be  slight  or  absent.     Again,  pain  may  be  constant,  and  in- 


RENAL  CALCULUS.  233 

creased  on  pressure  in  the  lumbar  region.  The  bladder,  as  a 
rule,  is  in  an  irritable  condition,  but  may  be  perfectly  normal, 
and  yet  severe  pains  in  the  bladder  region  may  occur  ;  tenes- 
mus, with  or  without  pain,  and  frequent  urination  may  all  be 
present.  The  microscopical  examination  of  the  urine  reveals 
epithelial  cells,  and  almost  always  red  blood-corpuscles — 
sometimes  suificiently  distinct  to  be  seen  macroscopically.  If 
infection  is  present,  pus-cells  are  also  necessarily  present. 
The  urinary  findings,  especially  of  blood,  are  of  importance. 
The  renal  stones — necessarily  small  ones — passing  into  and 
through  the  ureter  occasionally  become  impacted  and  cause 
special  symptoms  which  are  classed  under  the  name  of  "  renal 
colic."  This  attack  is  brought  about  by  the  obstruction  in 
the  ureter,  by  the  stretching  of  the  ureteral  tissues,  and  by 
the  spasmodic  contraction  of  the  ureteral  wall  in  efforts  to 
get  rid  of  the  impacted  stones.  The  symptoms  are  :  the 
patient  is  suddenly  seized  with  severe  pains,  which  usually 
start  in  the  renal  region  and  radiate  in  almost  any  direction 
— into  the  hypogastrium,  the  spermatic  cords  and  testicles, 
the  bladder,  the  glans  penis,  etc. 

This  pain  may  arise  during  sleep  or  at  any  time,  and  may 
be  so  severe  that  the  patient  collapses,  faints,  falls  into  a  cold 
perspiration,  temperature  rises  and  respiration  increases,  and 
pulse  becomes  small  and  rapid.  Nausea  and  even  vomiting 
set  in,  and  tenesmus  is  followed  by  the  voiding  of  small  quan- 
tities of  a  highly  colored  and  even  bloody  urine.  If  infection 
is  present,  pus  may  also  be  present  in  the  urine.  The  urine 
may  cease  to  pass  from  the  kidney  if  the  obstruction  of  the 
ureter  is  complete,  which  is  then  a  retention  anuria  of  this 
particular  side,  but  in  addition  a  reflex  anuria  of  the  other 
kidney  is  possible,  and  the  secretion  of  all  urine  is  then  com- 
pletely arrested ;  signs  of  collapse  arise ;  perhaps  death  may 
follow  from  the  ursemia.  The  duration  of  the  attack  is  vari- 
able, according  to  the  time  which  it  is  necessary  to  relieve 
the  impaction.  The  attack  ceases  promptly  as  soon  as  the 
stone  is  delivered  into  the  bladder,  or  when  its  position  inside 
of  the  ureter  is  changed  in  such  a  way  as  not  to  provoke  the 
spasmodic  contractions. 


234  DISEASES  OF  THE  KIDNEY. 

Whenever  kidney  stone  is  suspected  it  is  advisable  to  learn 
the  anamnesis  as  to  the  character  of  the  pain,  whether  or  not 
there  have  been  previous  attacks,  etc.  The  examination, 
especially  by  palj)ation  of  the  kidney,  may  give  information. 
The  examination  of  the  urine,  catheterization  of  the  ureters, 
or  collection  of  the  urine  with  the  segregator  may  be  of  the 
greatest  importance.  The  chemical,  physical,  and  microscop- 
ical examination  of  the  separated  urine  from  the  two  kidneys 
is  often  of  vital  interest.  The  examination  with  the  Rbntgen 
rays  is  often  sufficient  to  show  the  2^f'esence  or  absence  of  stone, 
and  in  other  cases  substantiates  a  diagnosis. 

Treatment  has  in  view  the  removal  of  the  stone  or  stones, 
the  improving  of  any  pathological  conditions  caused  by  them, 
and  also  the  prevention  of  their  recurrence.  To  remove  stones 
surgical  interference  must  be  depended  on,  although  whenever 
a  uric  acid  or  other  diathesis  is  present,  urocedin,  piperazin, 
urol,  carbonate  of  lithium,  and  alkaline  mineral  waters  are 
serviceable.  In  case  of  severe  pain,  morphine  in  sufficient 
quantity  to  control  it  must  be  given.  Whenever  renal  colic  is 
present,  hot  packs,  diuresis,  and  catharsis  should  be  invoked. 
In  all  cases  the  stone  should  be  removed,  and  not  the  kidney, 
if  relief  can  thus  be  obtained.  Whenever  there  is  severe  hem- 
orrhage, or  whenever  there  is  reflex  or  retention  anuria,  or  if 
signs  of  an  acute  infection  are  present,  these  are  all  indications 
for  an  immediate  operation.  Repeated  attacks  and  infection 
are  sufficient  causes  for  operation.  Only  when  the  urinary, 
the  physical,  and  the  Rontgen-ray  examination  are  negative, 
and  when  the  anamnesis  is  not  absolutely  positive,  operative 
interference  is  not  to  be  urged. 

The  incision  of  the  kidney  {nephrotomy)  is  the  operation  of 
choice  in  most  cases,  even  if  the  stone  is  in  the  pelvis  of  the 
kidney,  on  account  of  the  poor  results  in  pyelotomy — i.  e., 
incision  into  the  pelvis.  In  cases  of  impaction  in  the  ureter 
it  may  become  necessary  to  incise  the  ureter  in  order  to  remove 
the  stone.  Only  when  the  entire  kidney  parenchyma  is 
destroyed  or  where  the  impaction  is  so  severe  is  it  necessary 
to  remove  the  kidney  {nephrectomy). 


TUMORS  OF  THE  KIDNEY.  235 

Tumors  of  the  Kidney. 

Tumors  may  arise  from  the  kidney  substance  or  from  the 
pelvis  of  the  kidney.  Those  arising  from  the  fatty  capsule 
and  suprarenal  bodies  are  not  uncommon,  and,  as  they  can- 
not always  be  differentiated  clinically,  they  are  of  great  sig- 
nificance and  will  here  be  considered. 

The  benign  tumors — angioma,  lymphangioma,  osteoma,  and 
enchondroma,  lipoma,  fibroma,  and  adenoma — are  compara- 
tively uncommon  and  rarely  diagnosed.  Occasionally,  when 
they  become  of  sufficient  size,  it  is  possible  to  palpate  them, 
especially  the  lipoma  or  lipomyoma ;  these  are  often  under 
the  capsule  and  may  reach  the  size  of  a  hen's  egg. 

The  malignant  tumors — the  primary  sarcoma  and  cancer, 
angiosarcoma,  endothelioma,  perithelioma,  adenosarcoma — 
are  the  more  common  and  of  the  greater  importance. 

The  primary  sarcoma  may  occur  at  any  age.  Patholog- 
ically, the  tumors  are  of  mixed  types — may  be  either  single 
or  multiple.  As  regards  primary  cancer,  it  appears  in  two 
ways  :  as  nodules  distributed  throughout  the  kidney  or  dif- 
fusely throughout  the  parenchyma ;  the  former  referred  to  as 
nodulated,  and  the  latter  as  the  infiltrated  varieties.  They 
may  vary  from  the  soft  or  medullary  to  the  hard  or  scirrhus 
types.  Necessarily  the  tumors  vary  in  their  palpatory  find- 
ings. Besides,  the  malignant  tumors  do  not  necessarily  show 
marked  symptoms. 

The  adenosarcoma  or  the  embryonal  sarcoma  arising  in 
childhood,  commonly  in  the  first  to  the  fourth  year,  are  of 
much  importance,  and  take  a  rapid  and  malignant  course. 
Hemorrhages  are  comparatively  uncommon,  and  metastases 
are  often  present. 

Cystic  tumors  of  the  kidney  are  of  different  types  :  (1) 
Cystic  degeneration  of  the  kidney  ;  (2)  echinococcus  cysts. 
As  regards  the  former,  solitary  cystic  formation  has  no  prac- 
tical foignificance,  as  but  small  quantities  of  the  kidney 
parenchyma  become  destroyed.  But  when  there  is  polycystie 
degeneration,  in  which  the  entire  kidney  substance  may  become 
destroyed,  it  is  of  much  importance.     It  is  usually  congen- 


236  DISEASES  OF  THE  KIDNEY. 

ital,  although  it  may  develop  during  life ;  if  the  former,  then 
usually  both  kidneys  are  aifected.  Children  do  not  live 
long  under  it.  Practically,  the  only  sign  is  the  finding,  in 
the  region  of  the  normal  kidney,  of  a  large  tumor  studded 
with  rounded  nodulations.  The  acquired  form  is  of  greater 
significance,  and  the  diagnosis  is  not  easily  made.  The  tumor 
is  first  felt  on  one  side  and  later  also  on  the  other  side.  It 
may  give  rise  to  renal  colic,  and,  of  course,  to  symptoms  like 
any  other  kidney  tumors.  A  trace  of  albumin  and  hyper- 
trophy of  the  heart  may  occur. 

Treatment. — If  solitary  cyst,  extirpation  ;  if  multiple,  with 
severe  symptoms,  nephrotomy  and  drainage  or  aspiration  may 
give  relief.  Whenever  total  extirpation  is  undertaken,  the  sec- 
ond kidney  must  he  free  from  disease. 

The  echinococcus  cyst  has  been  met  with,  although  it  is 
very  uncommon.  The  cyst  develops  slowly  and  compara- 
tively without  symptoms ;  only  when  it  is  of  large  size  does 
it  become  noticeable.  If  such  a  cyst  bursts  and  empties 
itself  into  the  pelvis,  the  urine  will  show  the  hooMets  and 
daughter  cysts  which  are  so  characteristic  of  the  echinococcus, 
and  the  diagnosis  is  established  positively.  Nephrotomy, 
with  suturing  of  the  walls  of  the  cyst  to  the  edges  of  the 
incision,  and  thorough  drainage  are  indicated. 

Secondary  infection  of  the  raw  wound-surfaces  is  very  com- 
mon in  echinococcus  cysts.  It  is  best,  therefore,  always  to  pro- 
tect the  entire  field  carefully  with  gauze  pads  and,  when  possible, 
not  to  open  the  mother  cyst  at  all,  but  rather  to  ablate  it  "  in  tact 
and  in  mass." 

Tumors  arising  from  embryonal  suprarenal  tissue  occur- 
ring in  the  kidney  are  called  hypernephroma.  Their  classi- 
fication is  still  in  doubt,  yet  they  have  the  characteristics  of 
both  sarcoma  and  carcinoma.  Their  course  is  usually  quite 
slow,  and  consequently  there  are  apparently  no  symptoms. 
They  occur  usually  after  the  fortieth  year.  There  may  be  a 
dull  pain  in  the  lumbar  region,  and  later  a  tumor  may  be 
felt,  or  colicky  pain  may  arise  suddenly,  and  then  blood  in 
the  urine  may  be  noticeable.  Metastasis  may  also  arise, 
hence  operative  interference  is  advisable. 


PERINEPHRITIS.  22!7 

Diagnosis. — In  tumors  of  the  kidneys  it  is  to  be  remem- 
bered that  certain  tumors  arise  in  the  first  years  of  life, 
another  class  after  middle  age,  and  that  syphilis  and  tuber- 
culosis are  more  frequent  in  the  intervening  period.  Tumors 
are  readily  palpable  in  individuals  with  lean  abdominal  walls, 
and  in  those  cases  in  which  individuals  are  stout  and  have 
rigid  abdominal  walls  the  tumor  may  become  of  large  size 
before  palpation  becomes  possible.  If  progressive  enlarge- 
ment can  be  made  out  from  time  to  time  the  diagnosis  be- 
comes certain,  but  the  time  for  operative  interference  has 
possibly  been  passed.  The  tumors  may  give  an  outline  of  the 
kidney  and  of  the  pelvis;  the  body  may  be  covered  with 
nodules,  or  it  may  be  uneven,  etc.  The  consistency  varies, 
of  course,  depending  upon  whether  it  is  cystic  or  scirrhus, 
etc.  The  radiograph  may  give  the  outline  of  the  tumor  and 
of  the  kidney.  If  a  metal  bougie  is  passed  through  the 
ureter  and  a  skiagraph  is  then  taken,  valuable  information 
regarding  the  topography  may  be  obtained  ;  this  information 
may  be  useful  at  the  time  of  operation.  The  urine  may  con- 
tain debris,  possibly  numerous  tumor-masses,  epithelial  cells, 
and  blood.  The  last  may  coagulate  within  the  ureter  and 
take  the  shape  of  the  ureter.  The  quantity  may  be  large  or 
small.  Microscopical  examination  of  the  sediment  will  not 
always  give  the  key  to  the  diagnosis.  Chemically,  albumin 
is  usually  found  to  be  present.  Dull  pains  in  the  lumbar 
region  are  common.  "  Renal  colic "  may  rise  if  particles 
cause  obstruction.  '  Symptoms  of  vesical  irritation  may  also 
occur.  Varicocele  on  the  affected  side  has  been  noticed  and 
is  of  some  significance.  In  malignant  tumors  radiating  pains 
and  cachexia  appear. 

Perinephritis. 

By  this  term  is  meant  usually  a  chronic  inflammatory  proc- 
ess of  the  fatty  capsule  and  a  secondary  thickening  and  con- 
traction. It  may  also  become  a  purulent  process.  In  the 
case  of  tuberculosis  of  the  kidney,  stone,  nephritic  abscesses, 
etc.,  paranephritis  is  always  a  secondary  process,  and  the  term 


238      REMARKS  ON  OPERATIONS  ON   URETER,   ETC. 

is  often  applied  when  the  process  has  gone  on  to  suppuration 
— i.  e.,  paranephritic  abscess.  However,  such  a  condition 
may  arise  where  the  urine  has  always  been  negative  and 
where  the  kidney  is  healthy  at  the  time  of  operation.  In 
the  latter  cases,  where  there  may  be  a  history  of  traumatism 
or  over-exertion,  if  simple  drainage  of  the  abscess  is  made,  a 
rapid  recovery  often  results.  This  is  not  the  case  if  the  kidney 
is  affected — here  the  operation  depends  upon  the  cause,  and 
naturally  the  course  varies.  The  clinical  course  is  not  always 
the  same,  and  the  etiologic  factor  must  be  searched  for.  The 
onset  is  often  very  sudden,  with  acute  symptoms  of  chills, 
fever,  and  then  local  signs  of  a  phlegmon — pain,  often  radia- 
ting, increased  on  motion  and  on  palpation,  swelling,  and 
later  even  redness  of  the  skin.  Nausea  and  vomiting  may 
arise;  the  temperature  becomes  lower,  but  remains  irregular. 

The  diagnosis  cannot  always  be  made  very  early. 

Treatment  is  always  operative,  and  the  incision  always  from 
the  lumbar  region. 

REMARKS  ON  THE  OPERATIONS  ON  THE  URETER, 
PELVIS  OF  THE  KIDNEY,  AND  THE  KIDNEY. 

In  regard  to  the  surgical  procedure  involving  these  organs, 
a  few  general  facts  should  be  understood. 

The  kidneys  and  ureters  are  protected  anteriorly  by  the 
peritoneum.  It  is  best  to  avoid  entering  the  peritoneal  cavity, 
thus  probably  preventing  the  urine  from  entering  such  cavity, 
and  avoiding  subsequent  infection  by  the  germs  gaining 
access  thereto.  It  is  positively  known  that  bacteria  may  be 
eliminated  by  way  of  the  kidneys  through  the  urine,  and  the 
latter  contain  no  pus.  In  order  to  do  this  the  so-called  lumbar 
or  retroperitoneal  route  should  be  taken.  In  cases  of  large 
tumors,  in  certain  cases  of  floating  kidneys,  or  where  an  opera- 
tion must  be  performed  rapidly,  or  in  obstruction  of  the 
ureter,  an  incision  passing  through  the  protecting  layer  of 
peritoneum  may  become  advisable  ;  this  is  called  the  transper- 
itoneal route. 

Therefore,   the  retroperitoneal  incision  is  the    incision    of 


NEPHROTOMY,  NEPHBOBBHAPHY,  NEPHRECTOMY.    239 

choice  in  the  larger  number  of  cases.  The  incisions  vary  in 
number,  each  being  advocated  for  some  particular  purpose  ; 
hence  it  will  be  impossible  to  give  more  than  an  outline. 
However,  these  incisions  may  be  used  for  interference  on  the 
ureter,  pelvis  of  the  kidney,  or  kidney,  no  matter  what  the 
indication  is.  It  may  be  a  stricture  or  stone  of  the  ureter, 
pyelitis,  hydronephrosis,  perinephritic  abscess,  for  resection, 
or  for  therapeutical  effects  on  the  kidney,  as  splitting  the  kid- 
ney capsule  in  cases  where  the  tension  within  is  increased  and 
where  the  capsule  has  become  secondarily  thickened,  injuries 
to  the  parts,  floating  kidney,  or  whenever  incision  or  excision 
of  kidney  is  demanded. 

NEPHROTOMY,   NEPHRORRHAPHY,  AND    NEPHRECTOMY. 

Nephrotomy. — This  is  an  operation  for  opening  the  paren- 
chyma of  the  kidney  or  the  kidney  pelvis.  The  incision  of 
Simon  begins  at  the  twelfth  rib,  runs  down  in  a  vertical  line 
to  the  crista  iliaca,  parallel  to  the  anterior  border  of  the 
sacrospinal  muscle.  This  incision  is  often  insufficient,  as  it 
does  not  allow  a  thorough  manipulation  of  the  kidney.  It 
has  the  advantage  of  not  causing  much  tissue  laceration. 
Another  incision,  also  a  lumbar  incision,  is  made,  so  that  the 
direction  runs  obliquely  from  behind  forward,  commencing  at 
the  outer  edge  of  the  erector  spinae  muscle.  After  the  skin 
and  fat  are  split,  the  muscles  are  either  severed  by  cutting  or 
separated  by  blunt  dissection,  which  should  follow  the  course 
of  the  fibres  of  the  muscle.  After  this  is  done  the  renal  fat 
is  passed  through,  and  the  kidney  itself  is  approached. 

Nephrorrhaphy. — For  the  anchoring  of  a  floating  kidney  dif- 
ferent methods  are  devised.  While  several  operators  are 
satisfied  with  laying  sutures  through  the  parenchyma  of  the 
kidney  and  the  adjacent  muscles,  others  strip  off  the  renal 
capsule  or  form  flaps  out  of  the  latter  before  suturing.  Still 
others  make  a  pocket  for  the  lower  half  of  the  kidney,  or 
try  to  secure  the  kidney  in  its  normal  position  by  producing 
granulation  through  the  packing  of  the  cavity  or  by  closing 
the  peritoneal  pouch  in  wliich  the  kidney  is  movable.     All 


240     REMARKS  ON  OPERATIONS  ON   URETER,   ETC. 

these  methods,  however,  do  not  give  a  complete  guarantee 
against  recurrence. 

In  nephrotomy  the  kidney  is  shelled  out  of  its  fatty  capsule, 
and  by  blunt  dissection  is  made  as  movable  as  possible,  so 
that  it  can  be  brought  out  of  the  incision  or  "  delivered,"  as 
it  is  often  referred  to.  This  procedure,  however,  must  be 
done  very  carefully  in  order  not  to  injure  or  tear  any  of  the 
blood-vessels  which  run  in  the  renal  pedicle.  The  nephrotomy 
itself  may  either  consist  in  cutting  the  kidney  substance  open 
partly,  or  the  kidney  is  split  into  two  halves,  by  beginning 
the  incision  over  the  convex  border  and  leading  it  down  to 
the  hilus — the  so-called  postmortem  incision.  If  this  incision 
is  selected,  digital  compression  of  the  pedicle  will  serve  to 
prevent  hemorrhage.  After  manipulation  inside  the  kidney 
the  organ  may- be  closed  by  suturing  entire,  or  a  small  space 
for  the  insertion  of  a  drainage-tube  may  be  allowed  to  remain. 
In  all  cases  in  which  the  kidney  pelvis  is  incised  drainage  is 
to  be  instituted.  Of  course,  the  skin  sutures  may  be  partly 
or  entirely  united,  depending  upon  the  character  of  the  opera- 
tion. 

Nephrectomy  may  be  performed  either  by  the  above-men- 
tioned incision  or  by  the  so-called  transperitoneal  incision. 
Here  access  is  gained  to  the  kidney  by  the  usual  laparotomy 
incision.  The  posterior  parietal  peritoneum  is  split,  and  the 
kidney  is  loosened  and  removed  from  its  site.  The  ligation 
of  the  pedicle  must  be  done  very  carefully,  and  the  vein  and 
the  artery  should  be  ligated  separately. 

In  cases  of  tumors  incisions  or  combination  of  incisions 
may  be  made.  In  certain  cases  both  retroperitoneal  and 
transperitoneal  incisions  may  be  necessary.  Whenever  enter- 
ing from  in  front,  the  opposite  kidney  and  ureter  should 
always  be  palpated  carefully  in  order  to  be  positive  of  their 
presence  and  condition. 

QUESTIONS   ON   THE    ANOMALIES,    INJUEIES,  AND   DISEASES   OF 
THE  UEETERS,  PELVIS  OF  THE  KIDNEYS,  AND  KIDNEYS. 

Enumerate  the  anomalies  of  tlie  ureter.^. 

How  would  you  diagnose  and  treat  these  conditions? 

Do  injuries  to  the  ureters  ever  occur?    How? 


QUESTIONS.  241 

How  are  they  diagnosed  ? 

What  is  their  treatment  ? 

What  is  ureteritis  ? 

Wliat  other  pathological  conditions  of  the  ureters  are  met  with? 

What  is  their  treatment  ? 

What  is  hydronephrosis? 

What  is  the  pathology  of  this  condition  ? 

What  are  the  causes  of  this  condition  ? 

With  what  is  this  condition  often  mistaken? 

What  are  the  symptoms? 

Of  what  does  the  treatment  consist  ? 

What  palliative  methods  are  there  ? 

W^hat  is  pyonephrosis  ? 

Give  symptoms  and  treatment. 

What  is  pyelitis  ? 

What  is  meant  by  a  "  surgical  kidney  "  ? 

What  are  the  causes  of  pyelitis  ? 

Give  the  symptoms. 

How  is  the  diagnosis  made? 

What  is  the  prognosis? 

Describe  the  treatment. 

What  are  the  more  common  congenital  malformations  of  the  kidneys? 

Are  injuries  to  the  kidneys  common? 

For  practical  purposes,  what  classification  can  be  made? 

What  are  the  symptoms  in  the  diflferent  kinds  of  injuries?     Give  in  detail. 

What  is  the  prognosis  ? 

Give  their  treatment. 

To  what  may  hemorrhage  from  the  kidney  be  due  ? 

What  is  meant  by  an  "  essential  hemorrhage  from  the  kidney  "  ? 

How  is  the  diagnosis  made?     Whether  from  one  or  both  kidneys? 

What  is  the  treatment  ? 

What  is  meant  by  neuralgia  of  the  kidney? 

What  is  a  floating  kidney  ? 

How  would  you  make  the  diagnosis? 

Give  the  symptoms. 

What  treatment  is  to  be  advised  ? 

Does  syphilis  of  the  kidney  ever  occur?    In  what  diflferent  ways? 

How  is  the  diagnosis  made  ? 

What  are  the  symptoms? 

What  should  the  treatment  be  ? 

What  is  meant  by  tuberculosis  of  the  kidney? 

What  different  pathological  findings  are  there?  In  what  manner  do  the 
ureter  and  the  bladder  become  affected  in  these  cases? 

Give  the  symptoms.     Do  they  differ  in  different  cases?    Why? 

Is  tuberculin  useful  as  an  aid  to  diagnosis  in  the  doubtful  cases  ? 

What  does  the  treatment  consist  of? 

What  aids  are  used  in  establishing  the  fact  whether  one  or  both  kidneys 
are  affected  ? 

What  are  the  operative  procedures  undertaken?  What  are  the  indications 
for  each  ? 

What  is  meant  by  renal  calculus  ? 

Where  do  they  originate?  Are  the  form  and  size  influenced  by  any  con- 
dition? What  are  the  chemical  constituents  of  the  more  common  stones? 
What  is  probably  a  prominent  etiologic  factor  ? 

16  -V.  D.  , 


242     REMARKS  ON  OPERATIONS  ON   URETER,   ETC. 

Do  all  stones  produce  symptoms?     If  uot,  why  ? 

If  located  iu  the  pelvis,  what  symptoms  may  arise  ? 

Does  infection  often  occur  in  these  cases  ?    Why  ? 

What  are  the  more  prominent  symptoms? 

How  is  the  diagnosis  made  ? 

What  is  renal  colic  ?    Describe  this  condition. 

Does  reflex  anuria  ever  occur  in  these  cases  ? 

Ill  the  diagnosis  of  stone,  of  what  value  are  the  X-rays? 

What  is  the  prognosis? 

What  should  the  treatment  consist  of? 

Is  it  necessary  to  overcome  the  pain  ?  If  so,  with  what  ?  Is  medicinal  treat- 
ment of  any  special  value  ? 

What  operations  are  undertaken  in  these  cases?  What  are  the  indications 
for  the  difiFerent  operations? 

Are  tumors  of  the  kidney  ever  met  with? 

What  are  the  more  common  benign  tumors?  The  malignant  tumors?  Are 
they  primary? 

Describe  the  characteristics  that  carcinoma  may  take.  When  do  they  occur  ? 
At  what  age  is  the  adenosarcoma  met  with? 

To  what  symptoms  do  tumors  give  rise  ? 

What  kind  of  cystic  tumors  are  there  ? 

Have  the  solitary  cysts  any  great  significance  ? 

When  there  is  polycystic  degeneration,  of  what  importance  is  this  con- 
dition? 

Is  this  condition  congenital  or  acquired  ? 

What  is  the  treatment? 

What  is  the  echinococcus  cyst  of  the  kidney?     How  is  it  diagnosed? 

What  is  the  treatment  ? 

What  are  hypernephromata  ? 

What  symptoms  may  they  cause  ? 

From  what  other  tumors  must  they  be  differentiated  ? 

Give  the  differential  diagnosis  of  the  different  tumors. 

Give  the  treatment  for  the  different  types. 

What  is  a  perinephritis?    How  do  you  account  for  the  condition? 

Give  the  symptoms. 

What  is  the  treatment  ? 

Why  is  it  best  to  take  the  lumbar  route  in  operating  on  the  kidneys  and 
ureters? 

In  what  cases  is  it  necessary  to  take  the  abdominal  route  ?    Why  ? 

In  what  cases  is  splitting  the  kidney  capsule  done? 

Why  would  you  take  the  retroperitoneal  route?  Why  the  same  route  in 
floating  kidney,  stone  in  the  kidney,  etc.? 

Describe  the  operations  of  nephrotomy,  nephrorrhaphy,  nephrectomy. 
Give  in  detail  the  indications  for  these  different  operative  steps. 


INDEX. 


ABSCESS,  periurethral,  137 
prostatic,  142 
Adenitis,  23,  67 

acute,  43 

chronic,  44 

simple,  43 

strumous,  44 

suppurative,  43 
Albargiu,  9 
Albumin,  60 

Alopecia,  syphilitic,  27,  40 
Amyloid  bodies,  53 
Anaesthetic,  local,  80,  83,  150,  199 
Angioneurotic  disturbances,  226 
Anomalies  of  the  semen,  210 
Anorcliismus,  160 
Anuria,  66,  225,  233,  234 
Ardor  urinae,  106 
Argentamin,  108,  109 
Argonin,  108 

Aspermatismus,  55,  215,  216 
Aspermia,  55 
Asthenozoospermia,  215 
Atony  of  the  bladder,  1,  206 
Azoospermia,  171,  215 

BACILLUS,  Ducrey-Unna,  17,  41 
smegma,  60 

tuberculosis,  48,  59,  184,  229 
Bacterium  coli  commune,  48 
Bacteriuria,  58 
Balanitis,  22,  43,  68,  87 
Balano-posthitis,  87 
Ballottement  of  Guyou,  68 
Balsam  copaiba,  104 
Bas  fond,  203 
Benique  sound,  120 
Bicoude  catheter,  74,  75 
Bladder,  atony  of,  206 

examination  of,  72 

foreign  bodies  in,  192 

injuries  of,  181 

malformations  of,  179 


Bladder,  neuroses  of,  204 

paralysis  of,  206 

spasm  of,  205 

stone  in,  69,  193 

tumors  of,  190 
"  Blue  ball,"  43 
Bottini  incisor,  150,  151 

operation,  150 
Bougie-a-boule,  74,  75 
Bougie,  diagnostic,  71,  72 

filiform,  128 

olivary,  74 
Bubo,  23,  43 

chancroidal,  44 

indolent,  23 
Bubonulus,  43 

syphilitic,  22 

CALCULUS,  urinary,  2 
Calomel,  35,  39,  45 
Case  histories,  85 
Casper  cystoscope,  53 

urethroscope,  79 
Castration,  152,  177 
Catheter,  74 

English,  74 

fever,  48 

French,  74 

life,  148 

metal,  74 

Nelaton,  74 

permanent,  87,  201 

retention,  87,  201 

rubber,  74 

silver,  74 

soft,  74 
Catheterization,  76 

of  ureters,  53,  83,  222,  226 
Central  figure,  19 

Chancre,     difiierential     diagnosis     of, 
46 

extragenital,  22 

genital,  22 

243 


244 


INDEX. 


Chancre,  mixed,  43 

simple,  41 

soft,  41 
Chancroid,  17,  41,  90 

complications  of,  41 

course  of,  41 

differential  diagnosis  of,  46 

etiology  of,  41 

sequelse  of,  41 

symptoms  of,  41 

treatment  of,  44 
Charcot-Leyden  crystals,  54 
Choc  en  retour,  28 
Chordee,  101 
Circumcision,  88,  89,  91 
Colicystitis,  184,  185 
Colles'  law,  29 
Colliculus  seminalis,  81 
Condylomata  acuminata,  89 

lata,  23,  26 
Copper  sulphate,  122 
Corona  veneris,  25 
Coude  catheter,  75,  148 
Cowp'eritis,  137 
Cowper's  glands,  68,  81,  137 
Cryoscopy,  60 
Cryptorchismus,  160 
Crypts  of  Morgagni,  81 
Cystalgia,  205 
Cystitis,  169,  183 

acute,  184 

chronic,  184 

colli,  185 

dolorosa,  185,  189 

parenchymatous,  185,  189 

treatment  of,  186 
Cystoscope,  53,  83 
Cystoscopy,  82,  84 
Cystospasmus,  205 
Cystotomy,  suprapubic,  202 

DEEP  injections,  34 
Diday  irrigation,  170 
Dilatation,  continuous,  129,  134 

progressive,  129,  134 
Dilator,  Kollman,  134,  135 

Oherliinder,  134 
Discharges  from  urethra,  54 
involuntary,  54 
non-purulent,  54 
purulent,  54 
spontaneous,  54 
Dittel  urethral  rods,  128 
Divulsion,  134 
Dribbling,  125 


Ducrey-Unna  bacillus,  17,  41 
Ductus  ejaculatorii,  81,  139 
prostatici,  81 

EAELY  signs  of  syphilis,  20 
Echiuococcus  cyst,  235,  236 
Ectopia  testis,  161 

vesicfe,  179 
Ejaculatio  prsecox,  138 

prsematura,  145 
Electrolysis,  107,  133 
Elephantiasis,  92, 162 
Encircling  fibres,  125 
Enuresis,  65,  207 

diurna,  65,  207 

nocturna,  207 
Epididymis,  neoplasms  of,  175 

syphilis  of,  174 

tuberculosis  of,  172 
Epididymitis,  68,  169 

symptoms  of,  169 

treatment  of,  169 
Epispadias,  67,  94 
Esbach  albuminometer,  60 
Essential    hemorrages   from    kidney, 

226 
Evacuator,  197 
Expression  urine,  138,  145 
External  urethrotomy,  131 
Extragenital  chancre,  22 

FALSE  passage,  95 
Fistula  of  bladder,  183 
of  urethra,  126,  136 
Floating  kidney,  227 
Folliculitis,  urethral,  136 
Foreign  bodies  in  bladder,  192 
Fossa  navicularis,  81 
Fournier  treatment  of  gonorrhoea,  108 
Fungus  svphiliticus,  174 

testis,  172 
Funiculitis,  169 

pENITAL  chancre,  22 
vX     Genito-urinary  diseases,  17,  47 
examination  of,  85 
n  on -venereal,  47 
venereal,  47 
organs,  47 
Gleet,  98,  118,  119 
Gonococcus,  48,  50,  54,  59,  88,  96, 

102,  108 
Goiiorrhcea,  17,  47,  50,  96,  98 
abortive  treatment  of,  98 
acute,  anterior,  96 


INDEX. 


24^ 


Gonorrhoea,  acute,  posterior,  112 

iu  boys,  122 

chrouic,  anterior,  117 
posterior,  1J8 

complications  of,  47 

in  ferualeSi  122 

prophylactic  treatment  of,  99 
Gonorrhceal  cystitis,  184,  185 

rheumatism,  50 
Goutte  militaire,  25 
Gram  stain,  26 
Gumma,  26 
Guy  on,  49 

ballottement  of,  70 

capillary  catheter,  80,  120,  122 

HEMATOCELE,  166 
Hsematoma  scroti,  161 
Haematuria,  52,  53,  190,  225,  226,  231, 

233 
Hsemoglobinuria,  53 
Hand  injections,  107 
Harris,  195 

segregator,  53,  84,  226 
Hereditary  syphilis,  28,  40 
Hernia  of  bladder,  180 
Herpes  progenitalis,  88 
Homes'  lobe,  148 
Huuterian  chancre,  21 
Hutchinson  teeth,  30 

triad,  30 
Hydatids  of  Morgagni,  175 
Hydrocele,  163 

treatment  of,  164 

varieties  of,  164 
Hydronephrosis,  220,  232 

suppurative,  220,  232 
Hypertrophy  of  bladder,  189 
Hypodermatic  injections,  34 
Hypospadias,  67,  94 

TCHTHAEGAN,  107 
1     Ichthyol,  122 
Impotency,  210,  213 

varieties  of,  213 
Impotentia  coeundi,  215 

generandi,  215 
Incontinence  of  urine,  207 
Initial  lesion,  19,  21 

complications  of,  22 
Instillations,  107,  122 
Instrumental  examination,  70 
Intermittent  hydronephrosis,  220 
Intramuscular  injections,  34 
Intravenous  injections,  34 


Inversio  testis,  161 

Iodine  vasogen,  37,  45 

lodinism,  38 

lodipin,  37 

Iritis,  27 

Irrigations,  107,  111,  119,  122, 

TANET  irrigation,  170 


KELLY  cystoscope,  82 
Keratitis,  30 
Keyes  deep  urethral  syringe,  121 
Kidney,  floating,  227 

hemorrhages  from,  226 

injuries  of,  224 

malformations  of,  224 

neuralgia  of,  227 

stone  in,  231 

syphilis  of,  228 

tuberculosis  of,  228 

tumors  of,  235 
Koch  urethroscope,  80 
Kolischer  operation  cystoscope,  83 
Koranyi,  60 

LAFAYETTE  mixture,  105 
Lang's  gray  oil,  35 

method,   treatment    of  adeni- 
tis, 43 
of  stricture,  133 
Largin,  108 

Late  signs  of  syphilis,  20 
Lecithin,  54 
LeFort  catheter,  149 

sound,  129 
Leprosy,  19 
Leukoplakia,  25 
Litholapaxy,  196 
Litholysis,  196 
Lithotomy,  perineal,  196,  501 

suprapubic,  196,  202 
Lithotriptor,  196 
Lithotrites,  198 
Littres'  glands,  81 
Lofiier's  methylene-blue,  59 
Lubricants,  75,  83 
Lues  insontium,  22 
Lymphangitis,  43,  67 

MACULAE  syphilide,  24 
Massage  of  prostate,  145 
Masturbation,  216 
Meatotomy,  127 
Mercier  catheter,  75,  148 


246 


INDEX. 


Mercurial  dermatitis,  37 

folliculitis,  37 
Mercury,  32 

insoluble  salts  of,  35 

soluble  salts  of,  35 
Methylene-blue,  59,  60,  101 

test,  61 
Micturition,  52,  66 
Mixed  treatment,  88 
Moist  papule,  25 
Molluscum  contagiosum,  18 
Monorchismus,  160 
Mucous  patch,  23,  25 

NARGOL,  107 
JSTecrospermia,  55,  216 
Neisser's  treatment  of  gonorrhoea,  106, 

108 
Nelaton  catheter,  74 
Nephrectomy,  227,  231,  234,  236,  240 
Nephropexy^  228,  239 
Xephrorrliaphv,  228,  239 
Nephrotomy,  227,  231,  234,  239,  240 
Neuroses  of  testicle,  177 
Nitze  cystoscope,  52,  82 
Nocturnal  emissions,  210 
Non-specific  urethritis,  117 

rpDEMA  of  foreskin,  136 
\121     Oil  of  ciibebs,  104 

of  sandalwood,  104 
Oligospermia,  55,  171,  216 
Onanism,  211 
Onychia,  27 
Operations  on  bladder,  196 

on  kidney,  238 

on  pelvis  of  kidney,  238 

on  penis,  93 

on  prostate,  148 

on  seminal  vesicles,  139 

for  stricture,  130 

on  testicles,  160 

on  ureters,  238 

for  varicocele,  168 
Orchidopexy, 160 
Orchitis,  68,  172 
Organic  stricture,  124 
Organs  of  generation,  47 
Otis  urethrometer,  71,  127,  130 

urethroscope,  79 

urethrotome,  130 
Oxaluria,  58 

PAPULAE  syphilides,  24 
Pai'adoxical  incontinence,  206 


Paralysis  of  bladder,  206 
Paranephritis,  237 
Paraphimosis,  22,  43,  45,  67,  91 
Paronychia,  27 
Pediculosis  pubis,  18 
Pemphigus,  syphilitic,  30 
Penis,  epithelioma  of,  92 

fracture  of,  86 

infections  of,  92 

injuries  of,  86 

malformations  of,  86 

tumors  of,  92 
Pericystitis,  183 

Perineal  prostatectomy,  151,  152,  154 
Perinephritis,  237 
Periostitis,  27 
Periureteritis,  220 
Periurethral  inflammation,  137 
Pezzoli  massage  instrument,  149 
Phagedenic  ulcer.  43 
Phimosis,  22,  43,  44,  67,  90,  216 
Phlebitis,  hemorrhoidal  veins  of,  145 
Phloridzin  test,  61 
Phosphaturia,  58 
Piperazin,  234 
Pollutiones  diuruales,  210 

nocturnales,  210 
Pollutions,  210,  211 
Polycystic  degeneration,  235 
Posner  three-glass  test,  57,  138 
Posthitis,  67 
Potassium  iodide,  33 

permanganate,  108,  109 
Poteutia  coeundi,  213 

generandi.  213 
Preston  cystoscope,  53,  82 
Primary  sore,  19,  21 
Profeta's  law,  29 
Prostate,  abscess  of,  142 

diseases  of,  139 

gland,  139 

neoplasms  of,  152 

tuberculosis  of,  153 

tumors  of,  139 
Prostatectomy,  148,  151 
Prostatic  catheter,  75 

concretions,  153 

diagnosis,  148 

hjTiertrophy,  70,  71,  147,  169 

neurosis,  139 

treatment,  148 
Prostatitis,  118,  169,  170 

acute,  70 

chronic,  145 

differential  diagnosis  of,  147 


INDEX. 


247 


Prostatitis,  tuberculous,  70 
Prostatorrhoea,  55 
Prostatotomy,  148 
Protargol,  99,  122 
Pseudo-gouorrhcea,  17 
Psychrophor,  201 
Pus  in  the  uriue,  53,  60 
Pustular  syphilides,  26 
Pyelitis,  222 
Pyelotomy,  234 
Pyonephrosis,  222,  232 
Pyuria,  53,  60 

RADIOGEAPHY,  84 
Eeflex  anuria,  233 
Eeinfection  of  sj'-philis,  21 
Eeual  calculus,  231 

colic,  233,  237 
Eetention  anuria,  233 

of  testicle,  159 

of  urine,  65,  71,  75,  148.  169,  183 
Eicord's  mixtnre,  110 
Eupia,  26 
Eupture  of  bladder,  181 

QALIVATION,  36 

O  Scabies,  18 
Sclerosis,  19,  21 
Scrotum,  diseases  of,  161 

injuries  of,  161 

neoplasms  of,  161 
Segregator  of  Harris,  53 
Semen,  anomalies  of,  210 

losses  of,  210 
Seminal  vesiculitis,  138, 169, 170 
Sexual  disorders,  210 

neurasthenia,  211,  216 

operations,  152 
Silver  nitrate,  40,  45,  98,  122 
Sinus  pocularis,  81 
Smegma  bacillus,  60 
Snuffles,  30 
Soundins:,  76 
Sounds,  73,  74,  121 

diagnostic,  71 
Space  of  Eetzius,  202 
Spasmodic  stricture,  123 
Spasmus  vesica,  205 
Spermatocele,  175 
Spermato-cystitis,  138 
Spermatorrhoea,  211 

artificial,  211 

defecation,  55,  211 

micturition,  55,  211 
^permaturia,  211 


Staff,  132 

Sterility,  145,  210,  215 
Sterilization  of  instruments,  74 
Stone  in  bladder,  193 

chemical  analysis  of,  204 

crusher,  198 

forceps,  200 

in  kidney,  231 
Stricture,  68,  123 

diagnosis  of,  126 

elastic,  125 

hard,  125 

soft,  125 

symptoms  of,  124 

treatment  of,  128 
Stripping  seminal  vesicles,  139 
Sufficiency  of  kidneys,  61 
Suprapubic  cystotomy,  196,  202 

prostatectomy,  151 
Surgical  kidney,  223 
Syphilides,  23 

classification  of,  23,  24 

differential  diagnosis  of,  27 
Syphilis,  17,  19 

acquired,  19,  30 

choc  en  retour,  28 

congenital,  19 

course  of,  20 

contact,  19 

d'emblee,  21,  28 

etiology  of,  19 

gallopans,  28 

gravis,  28 

hereditaria  tarda,  30 

hereditary,  19,  21,  29 

of  kidney,  228 

maligna,  28 

prognosis  of,  28 

sequel®  of,  36 

symptoms  of,  19 
'  secondary,  19,  20,  27 
tertiary,  19,  20 

of  testicle,  174 

treatment  of,  30,  40 
Syphilitic  alopecia,  27 

bubonulus,  22 

choroiditis,  30 

contagiousness,  21 

deafness,  30 

eruptions,  23-26 

glands,  23 

initial  lesion,  21 

iritis,  27 

keratitis,  30 

onychia,  27 


248 


INDEX. 


Syphilitic  pains,  23 

Xjarouycliia,  27 

periostitis,  27 

reinfection,  21 

urethritis.  9(J 
Syphiloma,  23 

classilicatioo  of,  24 

ditierential  diagnosis  of,  40 

rriEXESMUS,  63,  64 
JL    Testes,  anomalies  of,  159,  161 
inflammation  of,  172 
injuries  of,  168 
luxations  of,  168 
neoplasms  of,  175 
retention  of,  159 
syphilis  of,  174 
tuberculosis  of.  172 
Thallin  sulphate.  122 
Thiosinamiu  hydrochlorate,  129 
Thompson  two-gla.^s  test,  55,  166 
stone  searcher,  77 
sound,  78 
Til  reads,  gonorrhceal,  57 
Tour  de  ventre.  76 
Treatment  of  balanitis,  87 
of  bladder  rupture,  183 
stone,  195 
tumors,  192 
of  chancroid,  44 
of  condylomata  acuminata,  81 
of  Cowperitis,  137 
of  cystitis,  186 
of  enuresis,  207 
of  epididymitis,  169 
of  floating  kidney.  227 
of  gonorrhoea,  98,  102 
of  herpes  progenitalis,  88 
of  hydrocele.  164 
of  hydronephrosis,  221 
of  impotency,  214 
of  kidney  tuberculosis,  230 

tumors,  236 
of  masturbation,  217 
of  orchitis.  172 
of  paraphimosis,  90 
of  phimosis,  90 
of  prostatic  abscess,  144 
hypertrophy,  148 
neuroses,  155 
of  prostatitis,  144 
of  pyelitis.  224 
of  renal  calculus,  234 
of  rheumatism,  gonorrhceal,  51 
of  sexual  disorders,  212 


Treatment  of  stone  in  bladder,  196 

in  kidney,  231 
of  stricture,  128 
of  syphilis,  hereditary,  40 

primary,  31,  32,  39 

secondary,  37,  32 

tertiary,'39,  37 
of  testicle  neuroses,  178 
of  urethral  fever,  50 

folliculitis.  137 
of  urethritis,  98.  102 
of  varicocele,  167 
of  venereal  warts,  89 
of  vesiculitis,  138 

ULCEE  of  bladder,  189 
phagedenic,  43 
Ulcus  durum,  21 

elevatum,  42 

molle,  41 
I'ltzman  capillary  catheter,  121, 122 
ITrsmia.  225 
Ureteritis,  219 

cystica,  219 
Ureters,  anomalies  of,  218 

diseases  of,  219 

injuries  of,  218 
Urethra,  carcinoma  of,  93 

examination  of.  72 

foreign  bodies  in,  95 

inflammatoiy  diseases  of,  96 

injuries  of.  95 

length  of,  72 

malformations  of,  94 

stricture  of,  123 

tumors  of,  95 
Urethral  dilators,  134 

fever.  48 
acute,  49 
chronic,  49 

folliculitis.  136 
Urethritis,  96,  169 

acute,  anterior,  98.  189 
posterior,  112,  189 

chronic,  anterior,  117 
in  females,  122 
posterior,  118 

complications  of,  136 

non-specific,  96 

specific.  96 
Urethro-cystitis.  185 
I      diS'erential  diagnosis  of,  189 
X'rethrometer,  71 
Urethrorrhoea,  54 
1      ex  libidine,  54 


INDEX. 


249 


Urethroscopes,  79 
Urethroscopy,  79,  124,  129 
Urethrotomy,  external,  131 

internal,  130 
Uric  acid  diathesis,  234 
Urinary  antiseptics,  105,  131 

calculi,  examination  of,  201 

diseases,  43 

fever,  48 

organs,  47 

overflow,  206 
Urination,  62,  66 
Urine,  48 

examination  of,  57 

expression  of,  55 
Urocedin,  234 
Urotropin,  105 

VAGIXAL  secretion,  97 
Vaginitis,  22,  43 
Varicocele,  68,  166,  251 


Varicocele,  symptoms  of,  167 

treatment  of,  167 
Vegetations,  43 
Venereal  diseases,  17,  18 

warts,  89 
Vesical  drainage,  204 
Volkmanu's  operation,  165 
Von  Bergman u's  operation,  165 
Vulvitis,  43 

WARTS,  venereal,  89 
Weichselbaum  stain,  60 


X 


RAY,  69,  192,  195,  234 


ZEISSL-LAXGELBERT  suspensory 
171 
Zinc  sulphate,  108,  110 
Zuckerkandl  incision,  139,  144 


v'\uf^^-^^ 


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